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COPYRIGHT DEPOSIT. 



GYNECOLOGICAL DIAGNOSIS 



GYNECOLOGICAL 
DIAGNOSIS 



BY 

WALTER L. BURR AGE, A. M., M.D. (Harv.) 

Fellow of the American Gynecological Society ; Member of the Obstetrical Society of 
Boston; Consulting Gynecologist to St. Elizabeth's Hospital ; Formerly Visiting 
Gynecologist to St. Elizabeth's and the Carney Hospitals ; Electro- 
Therapeutist and Surgeon to Out-Patients, Free Hospital 
for Women; Clinical Instructor in Gynecology, 
Harvard University, and Instructor in 
Operative Gynecology in the 
Boston Polyclinic 



WITH TWO HUNDRED AND SEVEN TEXT ILLUSTRATIONS 




NEW YORK AND LONDON 
D. APPLETON AND COMPANY 

1910 



-x? 









Copyright, 1910, by 
D. APPLETON AND COMPANY 



PRINTED IN NEW YORK, U. S. A. 



CCI.A268281 



;« 



"Find out the cause of this effect — 
Or rather say, the cause of this defect, 
For this effect defective comes by cause." 

— Hamlet, Act ii, Scene 



PREFACE 

Some years ago a prominent surgeon who had been attending one 
of my clinics, remarked when the clinic was over: "I think I under- 
stand the treatment and I know how to do most of the gynecological 
operations, but where I find great difficulty is in the diagnosis." 

At the present time the medical profession is devoting an ever- 
increasing amount of attention to diagnosis, and it seems fitting to 
describe at length this somewhat blind subject, gynecology, for the 
benefit of those who have not had an opportunity to study it in the 
special hospitals and clinics. 

A practical text-book, embodying simplicity of technique and 
concise statement of essentials, has been the aim. The methods of 
procedure of the pathological and bacteriological laboratories have 
been omitted because of the assumption that the physician in making 
a diagnosis has always at his command the services of a trained 
pathologist and bacteriologist, or can consult text-books devoted 
exclusively to these subjects. The attempt has been made to keep in 
the background the rare diseases which are of so much interest to the 
specialist and to give prominence to the common affections usually 
met by the general practitioner. While the book is written entirely 
from the clinical point of view, the salient points of the anatomy 
and the latest views of the pathology have been summarized at the 
beginning of each chapter, and the literature has been scanned for new 
ideas of value to the practitioner. 

The differential diagnosis is entered into extensively and is sum- 
marized in many places in the form of tables of parallel columns. 

Particular attention has been paid to the diagnosis of the diseases 
of the bladder and of the rectum because of my belief that these 
organs are too often neglected. A chapter on diseases of the breast 
has been included because the breast is a part of the reproductive 
system in women and has intimate relationship with the uterine 
organs. The importance of the recognition of uterine disease in early 
life, which, when undiscovered, frequently causes disastrous results 
later, has led to the writing of the chapter on the gynecological affec- 
tions of infancy and childhood. In the preparation of this chapter 
I have been fortunate in having the assistance of my friend, Dr. 



viii PREFACE 

John Lovett Morse, who kindly revised the manuscript. The chapter 
on the menopause is an attempt to shed light on this important but 
little understood period of woman's life. 

An original feature of the book is an alphabetical index of illus- 
trations — of which there are two hundred and fifteen — in the front. 
Thus the reader can find any desired figure without laboriously 
going through the entire list. The attempt has been made to place each 
figure next to the text it illustrates and all references to figures, as well 
as to subjects cited in other parts of the book, are accompanied by 
page numbers. Every chapter is headed by a resume of its contents 
with page references, and all the illustrations, as well as the titles of 
the subject-matter, are also included in a very full index at the end. 

The views here expressed and the methods described are those 
that have found favor in my practice, and they are put forward not 
with the feeling that they are new, original, or all-inclusive, but that 
having proved useful to me they may help others also to unravel the 
knotty problems of gynecology. 

My thanks are due to Dr. Howard A. Kelly, Dr. E. C. Dudley, and 
the other authors who have kindly loaned illustrations from their 
works; to Dr. Henry T. Hutchins for revising the chapter on malig- 
nant diseases of the uterus and the section on the collection of the 
discharges and tissues for microscopic examination; to Dr. Howard 
W. Beal for assistance with the section on indirect cystoscopy; to 
Miss Florence L. Spaulding and Miss Ruth O. Huestis for original 
drawings; and especially to Messrs. D. Appleton and Company, 
who have shown never-failing courtesy and who have assisted in every 
possible way in the making of the book. 

Walter L. Burrage. 
Boston 



CONTENTS 



PART I 

GENERAL CONSIDERATIONS 

PAGE 

Chapter I. Introduction 3 

Chapter II. The Clinical History 5 

Chapter III. The Interpretation of the Clinical History . . 9 

Chapter IV. The Physical Examination 23 

I. The preparation of the patient. — II. The prepar- 
ation of the examining table. — III. The exam- 
ination: 1. Preparation of the physician and 
placing the patient on the table. 2. Inspection 
of the external genitals. 3. Palpation. 

Chapter V. The Physical Examination {Continued) 43 

III. The examination {continued): 3. Palpation 
{continued). 4. Odor as a diagnostic sign. 5. The 
collection of the discharges and tissues for micro- 
scopic examination. 

Chapter VI. The Physical Examination {Continued) 64 

III. The examination {continued): 6. Inspection of 
the abdomen. 7. Palpation of the abdomen. 
8. Percussion of the abdomen. 

Chapter VII. The Physical Examination {Concluded) 77 

III. The examination {continued): 9. Instruments 
and their use in diagnosis. 

Chapter VIII. The Investigation of the Urethra, Bladder, and 

Ureters 99 

Chapter IX. The Investigation of the Rectum 121 

Chapter X. The Significance of the Chief Symptoms of Pelvic 

Disease 127 

ix 



CONTENTS 



Chapter XI. 
Chapter XII. 
Chapter XIII. 

Chapter XIV. 
Chapter XV. 
Chapter XVI. 

Chapter XVII. 
Chapter XVIII. 
Chapter XIX. 
Chapter XX. 
Chapter XXI. 
Chapter XXII. 

Chapter XXIII. 
Chapter XXIV. 
Chapter XXV. 
Chapter XXVI. 
Chapter XXVII. 
Chapter XXVIII. 

Chapter XXIX. 



PART II 

SPECIAL DIAGNOSIS 

PAGE 

The Diagnosis of Endometritis, Including Gonor- 
rhea and Erosions of the Cervix Uteri . . . 16.3 

The Diagnosis of Pelvic Inflammation (Pelvic 

Peritonitis and Pelvic Cellulitis) . . . 187 

The Diagnosis of Congenital Anomalies of the 
Uterus, Laceration of the Cervix Uteri, and 

Diseases of the Uterine Ligaments .... 197 

The Diagnosis of Malpositions of the Uterus . 215 

The Diagnosis of Fibroid Tumors of the Uterus 244 

The Diagnosis of Malignant Diseases of the 

Uterus 266 

The Diagnosis of Diseases of the Ovaries . . 284 

The Diagnosis of Diseases of the Fallopian Tubes 324 

The Diagnosis of Extra-Uterine Pregnancy . . 340 

The Diagnosis of Diseases of the Vagina . . . 354 

The Diagnosis of Diseases of the Vulva . . . 388 

The Diagnosis of Uterine Pregnancy, Abortion, 

and Hydatidiform Mole 417 

The Diagnosis of Diseases of the Urethra . . 444 

The Diagnosis of Diseases of the Bladder . . 457 

The Diagnosis of Diseases of the Ureters . . 486 

The Diagnosis of Diseases of the Rectum . . 494 

The Diagnosis of Diseases of the Breast . . 531 

The Diagnosis of the Gynecological Affections 

of Infancy and Childhood 555 

The Menopause and Old Age 587 

INDEX . 627 



LIST OF ILLUSTRATIONS 



FIG. PAGE 

Abdomen, cavity of, shape of 86 221 

division of, into quadrants and indication of bony landmarks . 18 65 

organs of, origin of tumors in . . 129 304 

Anal canal 191 495 

cast of 192 496 

Anal region, diagram of 195 515 

Applicator, uterine 37 93 

Ascites, abdomen of, seen in profile 131 307 

cross section of , dorsal position . 132 310 

lateral position 133 311 

Bartholin's gland, cyst of left 174 409 

Bartholin's glands, abscess of 176 411 

abscess of ducts of 175 410 

Bladder, ballooned by air, patient in knee-chest position 54 112 

base of, showing diverticula 185 458 

normal, laid open from in front 51 106 

overdistended 84a 217 

papilloma of 190 482 

stone in 186 463 

tuberculosis of ureteral orifice in 187 469 

varix of 188 474 

Bladder phantom, for practising cystoscopy 58 118 

Blood vessels, uterine and ovarian 8 47 

Body, vertical median section of 6 44 

of childbearing woman 84 216 

Breast, diffuse bilateral hypertrophy of 201 541 

dissection of lower half of, showing milk ducts 198 534 

division of, into quadrants 200 538 

lymphatics of 199 535 

right, vertical section of 197 533 

scirrhous cancer of 202 547 

Calibrator, meatus, Kelly 44 101 

Carunculse myrtiformes 165 397 

Catheter, bladder, long silver 43 101 

ureteral, Kelly 48 103 

Cervix, adeno-carcinoma of canal of, early stage Ill 268 

cancer of, early stage 110 267 

erosion of, with lacerations 69 185 

fibroid of 108 254 

hypertrophic elongation of 88a 225 

xi 



xii LIST OF ILLUSTRATIONS 

FIG. PAGE 

Cervix, laceration of, bilateral, with erosions 79 205 

crescentic 81 207 

stellate 80 206 

unilateral (diagram) 83 209 

with eversion of lips (diagram) 82 209 

prolapse of 88 224 

squamous-celled cancer of, early stage 110 267 

supravaginal, elongation of 88 224 

Controller, current, for use with electric cystoscope 57 117 

Curette, uterine 31 90 

Cylinder, vertical, filled with fluid, representing abdominal cavity . 7 45 

Cystocele 148 367 

diagram of 148a 368 

Cystoscope, bladder, Kelly 49 104 

ureter, Nitze 56 116 

Cystoscopy, modified knee-chest position used in 53 111 

removing urine from bladder in, by suction apparatus 55 113 

Decidua, uterine, in extra-uterine pregnancy 143 345 

Depressor, vaginal, Hunter 29 89 

Dilator, urethral, double-ended, Kelly 45 102 

uterine, Wathen 34 92 

uterine, Hanks 33 91 

Endometrium, normal 65 167 

Enteroptosis, body pose in 19 67 

Evacuator, bladder, Kelly 46 102 

wash-bottle, Kelly 55 113 

Extra-uterine pregnancy, ampullar, early 140 341 

mole and fetus removed 141 342 

ampullar, late 145 350 

isthmial, section of uterus of 146 352 

Fallopian tubes, development of, in fetus 71 198 

Fissure in ano 194 504 

Fistula in ano, blind internal 196a 517 

complete 196 517 

Fistulse, genital, scheme of, after Dudley 189 476 

after Gilliam 155 385 

Forceps, bladder, alligator 50 105 

curette, Emmet 30 89 

rectal, alligator 62 125 

uterine dressing, Bozeman 23 83 

vulsellum 25 84 

Gauze records of abdominal tumors 20 75 

Genital organs, development of, five diagrams illustrating . . 158-162 395 

external, at beginning of third month 157 392 

Gland, Bartholin's, cyst of left 174 409 



LIST OF ILLUSTRATIONS xiii 

FIG. PAGE 

Glands, Bartholin's, abscess of 176 411 

abscess of ducts of 175 410 

Hand, examining, showing protective sleeve 2 31 

Hegar's method of palpating pedicle of ovarian tumor 126 301 

sign, bimanual palpation for 179 425 

Hematocele, pelvic 142 343 

Hematocolpos, diagram of 171 398 

Hematometra, diagram of 172 398 

Hematosalpinx 139 335 

diagram of 173 399 

Hemorrhoids, types of 193 499 

Hydatidiform mole 182 442 

Hydrosalpinx 138 334 

Hymen, different forms of 163-170 397 

Interstitial pregnancy 144 346 

Irrigator, uterine, Bozeman-Fritsch 35 92 

Isthmial tubal pregnancy, section of uterus of 146 352 

Ligaments, utero-sacral, course of, in intraligamentous tumor . . 135 317 

in retroperitoneal tumor 134 316 

Maturity, precocious, case of 207 565 

"Milk line," 200 538 

Os, external, parous „ . 66a 169 

virginal . 66 168 

Ovaries, infantile 117 286 

Ovary, cyst and tumor regions of 120 290 

cyst of, adherent, arrangement of peritoneum in 124 292 

intraligamentous, arrangement of peritoneum in 123 292 

pedicle, arrangement of peritoneum in 122 292 

very large, showing emaciation and "facies ovarina " .... 125 294 

normal, pedicle, arrangement of peritoneum in 121 292 

of mature woman 118 287 

senile 119 289 

tumor of, cross section of body of 127 302 

tumors of, Hegar's method of determining relation of, to uterus . 126 301 

pedicle, formation of (4 diagrams) 121-124 292 

Ovary and tube seen from behind 116 285 

Parovarium, large cyst of, seen in profile 128 303 

Pelvimeter , .... 42 98 

Pelvis, contents of, from above 9 48 

female, normal 9a 50 

showing accessibility of contents to palpation 10 52 

with hand in position as for vaginal examination 4 37 

floor of, diagram showing structures of . 150 373 

of new-born child, longitudinal median section of 204 558 



xiv LIST OF ILLUSTRATIONS 

FIG. PAGE 

Perineum, laceration of, complete median 151 374 

partial lateral 152 375 

Peritoneum, reflections of folds of, in pelvis 70 189 

Position, dorsal 3 32 

knee-chest 13 56 

bladder, vagina, and rectum ballooned by air in 54 112 

modified for cystoscopy 53 111 

side-view, showing vertical thighs 14 57 

lithotomy 15 58 

raised pelvis 16 59 

Sims 11 53 

diagram of 12 54 

standing 17 60 

Precocious maturity, case of 207 565 

Pregnancy, extra-uterine. See Extra-uterine pregnancy 

interstitial , . 144 346 

tubal, early ampullar, abortion in 140 341 

mole and fetus removed from tube 141 342 

isthmial, uterus of 146 352 

late ampullar, four months' 145 350 

section of uterus, showing decidual modification in 146 352 

Probe, uterine 22 82 

Procidentia 87 223 

Proctoscope, long 61 124 

short 60 123 

Pyosalpinx 137 333 

Rbctocele . 149 369 

diagram of 149a 370 

Rectum, ballooned by air, patient in knee-chest position . .'. . . 54 112 

lower part of, diagram of 195 515 

Salpingitis, tuberculous 136 331 

Searcher, ureteral, Kelly 47 102 

Sound, uterine 21 78 

Separator, urine, Luys 59 119 

Speculum, bivalve. See Speculum, vaginal, Brewer and Graves 

rectal, Sims 63 126 

uterine, Burrage 36 93 

vaginal, Brewer 26 87 

Edebohls 32 91 

Graves 27 87 

Sims 28 88 



Table, examining 1 27 

Tenaculum, uterine 24 83 

Touch, bimanual, diagrammatic drawing 5 38 

Tubercles of bladder wall 187 469 



LIST OF ILLUSTRATIONS xv 

FIG. PAGE 

Ureter, orifice of, jet of urine spurting from 52 107 

Urethra, caruncle of ' 184 454 

mucous membrane of, prolapse of 183 449 

Uterine organs of an infant at birth seen from above 205 562 

Uterus, anteflexion of, in the little girl 90 230 

pathological 91 231 

bicornis 74 199 

bicornute, one external os, two uterine cavities 78 201 

bipartitus 72 199 

body of, adeno-carcinoma of, early stage 112 269 

horizontal section of upper part of .....' 67 171 

sarcoma of . . ' 113 279 

cavity of, Kelly's methods of exploration of, exploring with finger 41 97 

incising anterior wall 39 95 

transverse incision anterior to cervix 38 94 

laid open 40 96 

chorioepithelioma of posterior wall of 114 281 

development of, in fetus 71 198 

didelphys 73 199 

double, with double vagina 147 358 

fibroids of, interstitial and submucous 104 248 

intraligamentous . 105 249 

large tumor filling pelvis and simulating pregnancy .... 109 256 

multiple 102 246 

polyp in vagina, large 107 252 

submucous, large, showing distortion of uterine cavity .... 106 250 

simulating inversion 101 245 

pedunculated, simulating inversion 99 241 

simulating partial inversion 95 241 

subserous, side view of abdomen containing large tumor . . . 103 247 

tumor of cervix 108 254 

fundus of, height at various weeks of pregnancy 130 306 

inversion of acute puerperal 93 239 

complete 98 241 

with pedunculated subserous fibroid of abdominal evolution . 100 241 

partial 97 241 

caused by submucous fibroid 296 241 

of left horn 94 241 

normal, position of 6 44 

pregnant, enlargement of, in late pregnancy 181 428 

pregnant at sixth week, diagrammatic side view, during contraction 178 423 

during relaxation 177 422 

section of 178 424 

prolapse of 87 223 

partial 89 227 

reconstruction of, showing shape of uterine cavity and cervical 

canal 64 166 

retroposition with anteflexion 91 231 

retroversion of 92 235 

caused by overdistended bladder 84a 217 



xvi LIST OF ILLUSTRATIONS 

FIG. PAGE 

Uterus, sarcoma of 113 279 

section of, in isthmial tubal pregnancy 146 352 

transverse longitudinal 68 172 

septus 75 199 

unicornis 76 199 

with accessory corau 77 199 

Vagina, ballooned by air, patient in knee-chest position 54 112 

chorioepithelioma of, metastatic 115 282 

cyst of anterior wall of 154 381 

cyst of posterior wall of 153 380 

development of, in the fetus 71 198 

double, with double uterus 147 358 

infantile, examination of, with cystoscope 205 559 

longitudinal section of, showing S-shaped curve 85 219 

prolapse of 88 224 

Vulva, at beginning of third month of fetal life 157 392 

diagram of 156 389 

infantile 203 556 



PART I 
GENERAL CONSIDERATIONS 



CHAPTER I 
INTRODUCTION 

Diagnosis, the foundation of gynecology, is elusive. The con- 
sultant frequently hears it said by the attending physician, " Doc- 
tor, I know how to do this operation, but what puzzles me is to 
know when it is indicated." 

The educated touch is the keystone of the diagnostic arch; 
symptomatology, sight, instrumentation, microscopic findings, are 
but accessories. To train the touch requires time and application. 
As in learning any handicraft, the beginning is of great importance. 
Those who neglect to perfect themselves in the proper technique 
at the start, who never acquire "good form" as they say in athletics, 
never progress beyond a moderate degree of excellence. The 
practitioner who persists in making the bimanual examination with 
thejpatient in bed or on a yielding surface, or neglects to incommode 
her to the extent of causing to be loosened all clothing about the 
waist, never becomes, a good diagnostician. The reasons for this 
will appear later. 

There is no department of medicine in which the patient is less 
able to judge from her own observation of the correctness of the 
diagnosis than in gynecology. Unlike the dermatologist, for ex- 
ample, the gynecologist does not have trained upon his work the 
critical eye of his patient. 

She is unable, also, to judge of the nature of the treatment em- 
ployed. It is especially easy for a physician who has made an error 
in diagnosis to persist in a chosen line of treatment without dis- 
covering his mistake, for the relations between cause and effect are 
often most shadowy; also, consultations are relatively infrequent 
in this department of medicine. Because of the delicate nature 
of the confidences called for, and the sensitive portion of the 
anatomy involved, the patient shrinks from subjecting herself to 
repeated examinations at the hands of different physicians. 

3 



4 INTRODUCTION 

We have to do in this book with the question of diagnosis alone 
and it will be my endeavor to point out how best to make it. More 
stress will be laid on the interpretation of symptoms and signs in 
the light of experience than is usual in text-books on gynecology 
because it is thought thereby to help the practitioner. 

That pathological conditions may exist without any symptoms 
at all should never be forgotten. For instance, a woman may have 
a double uterus, detected for the first time at the gynecological 
examination which follows labor, or a patient may have a small 
dermoid tumor of the ovary, discovered only when she comes to 
the physician to learn why she has never had children. 

A judicious combination of the deductive and inductive methods 
seems to be the most practical way of presenting the subject; a 
result accomplished by describing the steps of the examination and 
the processes followed in arriving at a diagnosis, as nearly as may be, 
as they occur in actual practice. 

Particular attention is paid to the minutiae of the history-taking, 
the management of the patient, and the smallest details of the ex- 
amination, because of my belief that matters which seem trivial to 
many are in reality the solid groundwork of a correct diagnosis. 

Mistakes in diagnosis are unavoidable even in the experience of 
the most expert. To make a mistake because an inadequate ex- 
amination was made or no examination at all is an unpardonable 
sin. Experience teaches that finality in diagnosis is not always a 
possibility in gynecology, and even after the most painstaking 
history, analysis of the symptoms, and physical examination, we 
may fail to distinguish between two or three possible conditions. 
Our object is to reduce the uncertain cases to a minimum. 



CHAPTER II 

THE CLINICAL HISTORY 

Method of getting the history, p. 5. Case-record systems, p. 6. Form for 
case records, p. 6. 

METHOD OF GETTING THE HISTORY 

Many busy practitioners slight the clinical history, the taking 
of which should precede every physical examination. This is 
a mistake which carries its own retribution in the form of a slip- 
shod diagnosis. A clear and exhaustive history not only serves as 
a guide in making the physical examination, but also develops 
symptoms which otherwise may be overlooked. There are few 
cases which are not better diagnosed by a careful preliminary 
questioning of the patient. The physician gains his patient's con- 
fidence, so necessary for a successful physical examination. If she 
becomes prolix or strays from the important point, a question will 
often bring her back. It is well to note especially, perhaps b}^ 
underlining, the symptoms that seem most important to her, so 
that in subsequent interviews these may be under special observa- 
tion. It is generally better to talk with the patient alone when 
getting the history, as there are important facts which will be 
suppressed if a third person, whether a nurse or a relative, be present. 
Sometimes it happens, however, that important facts are to be 
obtained from the husband, and, in the case of a young girl, from 
the mother. A desirable practice is to review the history after the 
physical examination in the light of the facts brought out by the 
examination and to cross-question the patient as to the truth. 
Avoid, as far as possible, asking leading questions and assenting 
too readily to the answers. Be sure that the answers represent the 
truth. 

5 



THE CLINICAL HISTORY 



CASE-RECORD SYSTEMS 



A good method for case records is the envelope, card-catalogue 
system. A filing cabinet with several drawers is obtained. Large, 
ungummed envelopes, and also a set of cards just fitting into the 
envelopes and the drawers as well, are procured. For use at the 
bedside it has been my custom to carry in a leather pocket-case a 
block of prescription blanks, six by four inches, which fit the en- 
velopes of my filing cabinet. At the office I use cards of the same 
size. Every card and envelope is marked on the left-hand top 
corner with the patient's name and filed alphabetically in the 
cabinet. One advantage of the envelope system is that additional 
memoranda, such as notes on treatment and other data, may be 
filed in the same envelope, and it is not necessary to copy the notes 
taken at the bedside before filing them. 

Many gynecologists have printed case sheets, either in a book or 
as loose pages or cards. It is well to have some schedule to follow 
so that the same order may be observed in all cases and important 
facts may not be omitted. To the beginner a printed form is in- 
valuable, but to the physician of experience it is hardly worth while 
to take up desirable room on the cards with printing which may be 
of no use in many of the cases. The object is to get a schedule in 
mind, rather than to have it printed before you. 



FORM FOR CASE RECORDS 

Date : 

Name in full : 

(In the case of a married woman both own first name and hus- 
band's first name for purposes of future identification.) 
Address : Nationality : 

Occupation : Age : 

Social Condition : Single. Married, (how many years) 

Widow : (how many years) 
Children : (how many and ages) 

Miscarriages or abortions : (number, and at what weeks or months 
of pregnancy.) 



FORM FOR CASE RECORDS 7 

Diagnosis: 

Family History. — General predisposition to cancer, lung trouble, 
heart disease, kidney disease, or rheumatism. If the parents are 
dead, what were the causes of death. Early or late occurrence of 
the first menstruation and of the menopause, or the occurrence of 
dysmenorrhea or uterine disease in sisters or female relatives. 

Previous History. — Special reference to gynecological affections; 
as attacks of vulvar inflammation, or smarting with micturition, 
as indicating gonorrhea; "inflammation of the bowels," as indicat- 
ing pelvic inflammation; lack of control over the bowels or bladder, 
showing injury of the sphincter ani or of the pelvic floor; the 
account of any operation which may have been performed on the 
genital organs. The infectious diseases may point to inflammatory 
affections of the vulva and vagina in childhood. 

Menstruation. — Age at which first menstruation occurred ; whether 
normally established, the subsequent rhythm, duration, quantity, 
and quality of the flow; whether accompanied by pelvic pain, if 
so, the situation, character, and duration of the pain, also whether 
before, during, or after the flow; whether disturbances of other 
functions at the time of menstruation, as nausea, headache, de- 
pression of spirits; any recent irregularities in the rhythm, quan- 
tity, or character of the flow; intermenstrual pain, if so, exact dates 
of beginning and end of pain. Is menstruation accompanied by 
leucorrhea, or not. 

Vaginal Discharge. — Character, amount, when most in quantity, 
duration. 

Pain. — Other than menstrual, situation, duration, character. 

Confinements, Miscarriages, and Abortions. — Labors normal, rapid, 
tedious, or instrumental; whether injuries received or symptoms 
suffered; convalescence normal or not; stitches taken, fever 
following. Miscarriages or abortions, dates of occurrence and at 
what weeks of pregnancy; supposed cause or causes; attended by 
much flowing or fever; convalescence, good or bad. 

Bladder Symptoms. — Frequency of micturition by day and by 
night; smarting on urination; control of urine on laughing and 
coughing and on standing and walking; pain in region of bladder 
on micturition ; color and quantity of urine passed. 

Present Illness. — Duration; particulars as to present symptoms 
such as pain, situation, character; leucorrhea, when first noticed, 



8 THE CLINICAL HISTORY 

character, as thin, glairy, thick, purulent, bloody, or offensive; 
whether constant, or before and after menstruation. 

Date of the Beginning of the Last Menstruation. 

Abdominal Swelling. — When first noticed, progressive increase 
in size, stationary or smaller, painful or not. 

Bowels. — Regular movement every day or constipated; full 
action or scanty; liquid, semi-solid, or solid stools; offensive odor; 
gas in bowels; blood, mucus, or pus with the stools; painful de- 
fecation. 

General Health. — Appetite, digestion, sleep; whether an increase 
or decrease in body weight ; headache ; backache. 

The General Appearance of the patient should be noted as 
regards height, approximate weight, complexion, color of lips, 
peculiarities of form, if any. 

Analysis of Urine. 

Treatment Advised. 



CHAPTER III 

THE INTERPRETATION OF THE CLINICAL HISTORY 

The address, nationality, and occupation, p. 9. Age, p. 9. Social 
condition, p. 10. Dypareunia, p. 11. Children, 11. Family history, p. 12. 
Previous history p. 12. Constitutional diseases, p. 12. Chief complaint 
and present illness, p. 13. Menstruation, p. 13: Puberty, p. 14; The 
menopause, p. 16; The atrophic changes in the genital organs and the 
body alterations of the menopause, p. 17. Vaginal discharge, p. 18. Pain, 
p. 18: Backache, p. 18; Muscular rheumatism, p. 19; Coccygodynia, 
p. 19; Pains in the groins, p. 19. Abdominal swelling, p. 20. Bladder 
symptoms, p. 20. The bowels, p. 21. Present illness, p. 22. 

This is a chapter of probabilities ; not instructions how to make 
an offhand diagnosis, but a sifting of the evidence as it is presented, 
the diagnosis being held in reserve until after the physical examina- 
tion, and until after any supplementary evidence has been elicited 
in the way of answers to questions which may be suggested by the 
examination. 

A knowledge of the normal conditions is essential, if the value of 
the abnormal symptoms is to be estimated correctly. 

The Address. — This is important not only as a matter of business 
but ae showing the possible effect on the patient's health of a healthy 
or an unhealthy locality. 

Nationality. — The colored race is especially prone to fibroids. 
Cancer is seldom found in a negress. 

Occupation. — Confinement in poorly lighted and ventilated work- 
shops, long working hours, heavy lifting, insufficient food and pro- 
longed standing on the feet aggravate, if they do not cause, pelvic 
disorders. On the other hand, a sedentary life with no real exercise 
may act as a contributory cause of pelvic disease. 

Age. — The age of the patient suggests the special disturbances 
found in the various epochs of life. In infancy malformations and 
inflammations of the lower genital tract are to be expected. At 
this time the infections are generally limited to the vulva and 
vagina, and tumors, displacements, and traumatisms seldom exist. 
Vulvo-vaginitis is not uncommon in little girls. 

9 



10 INTERPRETATION OF THE CLINICAL HISTORY 

Failure of the menses to appear previous to the sixteenth year 
should excite no apprehension ; after that it is apt to indicate under- 
development of the uterine organs. 

During the period of sexual maturity nearly all of the lesions of 
the genital organs may be found. The effects of gonorrhea are 
seen most often between the ages of twenty and thirty. Tumors 
of the breast are most frequently malignant between the ages of 
forty and sixty. Under the age of thirty-five a large abdominal 
tumor is more likely to be ovarian ; after that age it is more apt to 
be a uterine fibroid. 

A patient suffering from uterine hemorrhage more probably has 
endometritis or a polypus if under twenty; a polypus or some 
condition resulting from gestation, from twenty to thirty; fungous 
endometritis, polypus, or fibroids from thirty to forty; fibroids and 
malignant disease from forty to fifty. After fifty, malignant 
disease is the probability. 

Social Condition. — Congenital malformations may be brought to 
the patient's attention for the first time after marriage. Certain 
inferences may be drawn from the single or the married state of a 
patient as regards the cause of menorrhagia or metrorrhagia, as 
shown by the tables on pages 137 and 139, Chapter X., also as 
regards leucorrhea, as found on pages 144-146. Pregnancy is 
always to be considered if the patient is not a virgin. An early 
question as to the patient's social state, whether single, married, 
or a widow, may obviate embarrassing queries as to sexual re- 
lations and may throw light on the possible causes of her com- 
plaints. For instance, a recently married woman, always a sufferer 
with dysmenorrhea, finds the symptom aggravated and unbearable 
since her marriage. A periodic pelvic congestion, due to mal- 
position or malformation of the uterus, has been accentuated by 
the congestion which attends sexual relations. A recently married 
woman complains for the first time of smarting on urination, and 
leucorrhea. Suspicion of infection with the gonococcus at once 
arises in the physician's mind. The possibility of pregnancy or 
venereal infection should never be lost sight of, notwithstanding the 
patient's statement that she is single or a widow, great caution and 
tact being exercised, however, in making inquiries. The final 
question as to the truth or falsity of the suspicion should be left 
until after the physical examination in any event, and in many 



CHILDREN 11 

cases can not be made at all without causing serious and unjustifi- 
able trouble in the family of the patient. 

Dyspareunia. — Dyspareunia dating from the time of marriage 
indicates smallness of the introitus vaginae or urethral caruncle, 
if the pain is at the beginning of coitus. If the pain is experienced 
after the penis has been introduced into the vagina the cause is 
apt to be pelvic inflammation or a tender cervix or ovary. 

Children. — Sterility. — The absence of children may be important, 
for if a patient has been married many years and has not been 
pregnant, the inference is that the cause of the sterility rests with 
her and not with her husband, the latter being in good health, and 
we may expect to find some underdevelopment or malformation 
of the sexual organs. If there is any doubt as to the husband's 
virility a specimen of his semen should be examined for sperma- 
tozoa before subjecting the wife to gynecological treatment. 
(See Chapter X., page 147.) 

Carcinoma of the cervix, common in parous women, is rare in 
nulliparae, whereas cancer of the body of the uterus is more apt to 
occur in women who have not borne children. Complete or rela- 
tive sterility is often found in women suffering with fibroids. 

Number of Children. — The number of children a woman has had 
is important because child-bearing without a sufficient interval of 
recuperation between the labors frequently results in some sort 
of pelvic ailment. Therefore, note the ages of the children. The 
history of each confinement is of the greatest service in determin- 
ing the origin of a pelvic inflammation, a misplacement of the 
uterus, or lacerations. A difficult forceps delivery followed by 
fever and a tedious convalescence may mean all three, though not 
necessarily. 

Miscarriages and Abortions. — A history of each miscarriage or 
abortion should be secured with reference to the birth of children ; 
if before, the interruption of labor can not be due to injuries re- 
ceived at labor; if subsequent to a difficult and complicated con- 
finement, an abortion may w T ell be caused by the labor. The 
probable cause of an abortion in the patient's estimation, whether 
attended by hemorrhage or fever and how long the patient was 
confined to her bed, are points to be ascertained. These facts often 
reveal the starting point of an attack of pelvic inflammation, or 
anemia and subsequent debility due to loss of blood. If repeated 



12 INTERPRETATION OF THE CLINICAL HISTORY 

abortions have occurred they may indicate syphilis, tuberculosis, 
or a deeply lacerated cervix. 

Family History. — How much of a role heredity plays in the 
etiology of pelvic disease is not determined. Cancer and tuber- 
culosis are found occasionally in members of the same family. It 
sometimes happens that several sisters will all have a similar lesion 
of uterine underdevelopment. I have seen three sisters, each 
suffering from marked pathological anteflexion. A premature or 
delayed occurrence of the menopause is frequently a family charac- 
teristic. So is the symptom of dysmenorrhea. Family history, as 
a rule, does not have an important influence on diagnosis. 

Previous History, on the other hand, is of great importance. We 
have noted how an abortion may be the starting point of an attack 
of pelvic inflammation to be followed, perhaps years later, by serious 
lesions of the pelvic organs. So a history of " inflammation of the 
bowels," without assignable cause, may mean pelvic inflammation, 
the nature of the treatment employed at the time of the attack 
throwing some light on the probable diagnosis. 

An attack of soreness of the vulva associated with a purulent 
discharge, with or without smarting on urination, may well mean 
gonorrhea. 

Adhesions of the labia minora, and of the prepuce to the clitoris, 
and even imperforate hymen, may be caused by inflammation of 
the vulva in childhood due to diphtheria, scarlet fever, measles, or 
gonococcus infection. Nocturnal enuresis is caused, sometimes, 
by adhesions of this sort. Therefore, when possible, the mother 
of the patient should be questioned whether her daughter had 
vulval soreness and discharge when a child. 

A lack of control over the bowels when loose, during the months 
following a labor, leads us to expect to find injury of the sphincter 
ani, also inability to control the urine when standing, or on laugh- 
ing and coughing, make us look for injury of the vaginal wall and 
perineum and dislocation downward of the urethra. 

Injury of the pelvic floor is present if the patient complains of 
the noisy escape of air from the vagina when she suddenly changes 
the position of her body, or strains. 

Constitutional Diseases. — All general constitutional diseases have 
a bearing both as causative agents and aggravating influences on 
pelvic disorders; therefore they should be inquired into in getting 



MENSTRUATION 13 

the history. It so often happens that a woman in her usual good 
health is not seriously incommoded by a pelvic lesion and when 
pulled down by a long illness is overwhelmed by uterine symptoms. 
The physician should move slowly in drawing conclusions as to 
cause and effect, and also in judging of the weight to be attached 
to the uterine disease. 

It should never be forgotten that the whole is greater than any 
one part and that general constitutional diseases take precedence 
over gynecological affections. It is the sick woman we are to treat. 

Chief Complaint and Present Illness. — It is very easy for the en- 
thusiastic specialist to bend his energies to the making of a new 
ostium to a diseased Fallopian tube, or to the resection of a diseased 
ovary, quite forgetting for what the patient consulted him; that 
because he has found an abnormality of the pelvic organs, this 
must of necessity be the cause of the symptoms. He loses sight of 
the symptoms and doesn't always make a proper effort to relieve 
them, being led away on a futile hunt for anatomical perfection. 
Note, then, your patient's chief complaint, and when you have 
finished with the case, turn to your notes, refresh your memory, 
and see whether this complaint has been relieved. 

The duration and character of the present symptoms should be 
noted, such as pain, leucorrhea, abdominal swelling, and symptoms 
relating to the bowels or bladder, and do not slight the indications 
of the state of the general health as shown by the amount and 
character of the sleep, the state of the digestion, and the strength to 
accomplish customary daily tasks. 

Menstruation. — Menstruation may be defined as a discharge of 
bloody fluid which takes place from the uterus at stated periods 
throughout the time of sexual activity in the life of women. The 
causation of the discharge is still in doubt. 

Frankel ("Die Function des Corpus luteum," Archiv fur Gyn., 
LXVIIL, 1903, 438) considers that the corpus luteum in the ovary 
has a determining influence on menstruation. It is plain that the 
ovaries have something to do with this function because, when they 
are removed, menstruation ceases. As menstruation occurs only 
in human beings and some of the higher apes, it is difficult to settle 
the relation of menstruation to ovulation and to the normal or 
abnormal corpus luteum by animal experimentation. 

The mechanism of menstruation consists of a diapedesis of 



14 INTERPRETATION OF THE CLINICAL HISTORY 

blood through delicate capillaries, newly formed in a thickened 
and congested endometrium, the vessels for the arterial supply 
being more capacious than those for the venous return. Some of 
the capillaries rupture and the blood flows out. 

The flow at first is mucus streaked with blood, during the height 
of menstruation it is blood mixed with a little mucus, and toward 
the end it becomes more mucous in character. Menstrual blood 
is dark in color, alkaline in reaction, and, because of the mucus it 
contains, does not clot unless the mucus happens to be deficient. 
The mucus renders it more watery than ordinary blood. It has 
a peculiar odor given to it by the sebaceous glands of the vulva 
which are especially active during menstruation. 

Puberty. — The average age at which menstruation is established, 
in temperate climates, is fourteen years. Variations of a year or 
two from this type occur within normal limits. It occurs earlier 
in the city girl who is subjected, perhaps, to intimate association 
with the other sex and to sexual temptations, than it does in the 
country girl, or in a girl carefully brought up in comparative seclu- 
sion. This rule applies to the lower animals. If a bull is placed 
in the pasture with a herd of heifers, heat appears earlier in the 
heifers than it does when they are segregated. In women of strong 
sexual passion the function of menstruation is established earlier and 
lasts longer than common. 

The discharge of ova from the Graafian follicles of the ovary 
has been known to take place before menstruation is established, 
and it may continue after the menopause. The functions of 
menstruation and ovulation are not directly dependent one on the 
other, but both appear to be governed by the same portion t of 
the sympathetic nervous system. Cases of precocious menstrua- 
tion are occasionally reported, and it has been known to occur as 
early as a few days after birth. There are many cases on record 
of menstruation at a few weeks or months of age. Development 
of the external genital organs and the breasts, increase in body 
size, and often the growth of hair on the pubes goes with precocious 
menstruation. The diagnosis is not established unless the loss 
of blood recurs at monthly intervals and a physical examination 
of the child shows evidences of premature development. 

It is unusual for menstruation to be established before the twelfth 
year. On the other hand its appearance is seldom delayed beyond 



MENSTRUATION 15 

the eighteenth year. A case is on record, however, where a woman 
married at thirty-four, menstruated for the first time at forty-five, 
and bore a child at forty-six. According to the investigation of 
Rossi-Doria, an Italian physician, who recorded the data in over 
thirty thousand women, delayed menstruation goes hand in hand 
with pelvic disease. He found 39.21 per cent of pelvic malforma- 
tions in women who had not menstruated until twenty years or 
over. 

The normal rhythm of menstruation is a lunar month of twenty- 
eight days. A woman may enjoy perfect health in every respect 
and yet vary many days from the normal rhythm. Many women 
menstruate every three weeks, others every five weeks, with perfect 
regularity. In getting a history of the menstrual function it is 
necessary to specify the rhythm of the flow as well as the regularity. 
It is well to remember also that some women are regular at times 
and irregular at other times. 

The duration of the flow is from four to seven days. Here also 
a variation within normal limits of two days either way is to be 
noted. The greatest amount of blood is lost in the first two days. 
A discharge of mucus before and after the flow is common. The 
average amount of blood lost at a single menstruation is from four 
to six ounces. It is impracticable to measure this exactly and we 
are forced to resort to the inexact method of counting the number 
of napkins used. As the napkins vary in size, are used to the 
point of saturation by some women and barely stained by others, 
no definite information can be obtained. Inquiry on these points, 
however, will give the physician an approximate estimate which 
should be recorded in detail in his notes. About two well-saturated 
napkins a day may be considered as being normal. 

Whether menstruation is excessive in any given case depends in 
a certain measure on the physique of the patient; a full-blooded, 
plethoric woman may menstruate eight or nine days, using three or 
more well- saturated, large napkins a day; while an anemic, thin 
woman may be depressed by the amount of blood lost in a period 
of four days, using two napkins a day. 

The character of the flow is of importance. Note clotting, an 
acid reaction, a bright arterial color, and any change in odor. 

Attendant disturbances of other functions, before, during, and 
after menstruation, such as nausea, headache, depression of spirits, 



16 INTERPRETATION OF THE CLINICAL HISTORY 

variations in the action of the bowels or bladder, are very commonly 
observed, and should be chronicled. 

Menstruation is generally attended with a greater or less degree 
of a sense of fulness and weight in the region of the pelvis; often- 
times a certain amount of pain is to be considered as not abnormal. 
The menstrual period is a time of instability of the circulation and 
of the nervous system. The body temperature is slightly elevated, 
the thyroid gland is enlarged, and the tonsils and vocal cords may 
be swollen so as slightly to impair the singing voice; so also, in some 
cases, there are salivation and swelling of the mucous membrane 
of the turbinate bones at this time. There is increased vascular 
tension and increased secretion of the sweat glands and of the 
sebaceous glands, especially those of the external genitals. Some 
women are affected by skin diseases at their catamenia, notably 
herpes, or small macular ecchymoses about the flexures of the 
elbows or knees. 

A rhythmical wave of all the physiological processes has been 
demonstrated by Von Ott. The greatest activity is manifest just 
before the appearance of the flow, shown by increase of muscular 
strength, tendon reflexes, lung capacity, and heat production. The 
least activity is during the flow, the lowest point being reached on 
the fourth day. There is a slight reaction in the week following the 
cessation of the flow, an intermenstrual equilibrium of two or three 
days, to be followed by a gradual rise to a maximum two days be- 
fore the next flow, and so on from month to month. 

The Menopause. — The climacteric or cessation of the flow usually 
occurs from the forty-fifth to the fiftieth year, the discharge at 
this time becoming less and less in amount and of irregular occur- 
rence, gradually stopping altogether in from six months to two 
years. Menstruation may stop short without any period of irregu- 
larity and there may be no disturbance of the nervous system, 
although the latter is more common. 

If a woman begins to menstruate early the menopause is apt to 
be late, and vice versa. It is a family characteristic sometimes to 
have the menopause early or late. In case of fibroid tumors of the 
uterus the menopause is commonly delayed until the fiftieth year 
or later, and in subinvolution and chronic metritis the menopause 
comes late. 

Vasomotor disturbances are to be looked for during the meno- 



MENSTRUATION 17 

pause. The monthly rhythm which has existed since the fourteenth 
year is to be done away with, the sexual organs are to atrophy and 
become functionless. If the woman is in perfect health we shall 
expect nature to accomplish the change gradually as it was estab- 
lished, and without an upsetting of the general health. Too often, 
for one reason or another, the health is not rugged, then ensue hot 
flashes, sweating, palpitation, headaches, nervous irritability, and 
derangements of function in many organs, more especially those 
most closely controlled by the sympathetic nervous system. 

It is a mistake to consider uterine hemorrhage as a part of the 
normal menopause. It seldom occurs unless there is a definite local 
cause in the shape of a fibroid tumor, a cancer, chronic subinvolu- 
tion with hyperplastic endometritis, misplacement of the uterus, 
or other lesion. These uterine diseases may have caused no symp- 
toms, though existent for many years. Search should always be 
made for them. 

The Atrophic Changes in the Genital Organs and the Body Altera- 
tions of the Menopause. — The changes in the genital organs and in 
the body consist of (a) shrinking of the uterus in size. The mus- 
cular tissue becomes less thick and gradually the uterine cavity is 
shortened or even obliterated, the mucosa becoming thinned and 
the glands reduced in number. The epithelial cells grow smaller 
and lose their cilia. The vaginal portion of the cervix shrinks and 
does not project into the vagina, (b) The vagina is shortened and 
narrowed and its walls lose their elasticity and the mucous mem- 
brane its rugae, (c) The ovaries shrink to small knobs of fibrous 
tissue, the Graafian follicles disappear, and the Fallopian tubes 
become mere cords, (d) The fat disappears from the vulva, the 
labia majora become flabby, and the mons veneris loses its prom- 
inence, (e) The pubic hair turns gray after the hair of the head 
has lost its color. (/) The breasts also atrophy and become flabby, 
and (g) the body weight is increased. 

The menstrual flow may cease prematurely at an early age, even 
as early as the twenty-fourth year, the causes being general or local. 
As to the general causes not much is known beyond that they have 
to do with the nutritive and vascular systems. 

The local causes arc diseases which destroy the ovaries, as chronic 
infective inflammation, and removal of the ovaries by operation. 
It is worthy of remark that when functionating ovaries have been 
2 



18 INTERPRETATION OF THE CLINICAL HISTORY 

removed the distressing nervous symptoms of the climacteric are 
much more severe than when the menopause occurs with the 
ovaries in place. (The menopause is discussed fully in Chapter 
XXIX.) 

Vaginal Discharge. — Any discharge from the vulva is popularly 
referred to as leucorrhea or whites. A certain amount of moisture 
is normal and is made up of the secretions of the sebaceous and 
sweat glands of the vulva, the lubricating mucus secreted by the 
glands of Bartholin lying in the posterior portion of the labia majora, 
— most active during times of sexual excitement, — and by the 
secretions of the uterus. 

The vagina has no secretion proper and no glands, the vaginal 
secretion, so-called, being that poured out of the uterus together 
with epithelium and bacteria made acid by a bacterium which 
flourishes in the vagina under normal conditions. The fluid is 
milky and small in amount. The secretion from the cervix is 
tenacious, transparent, and thick ; that from the endometrium of 
the uterine cavity is clear, transparent, and thin. Both have an 
alkaline reaction. 

Skene's glands at the orifice of the urethra also secrete a mucus, 
which is thought to protect the meatus urinarius during coitus. 
Under normal conditions the combined discharge should not soil 
the clothing except just before and just after the menstrual 
periods, when all the secretions are increased in amount and may 
necessitate wearing a napkin. 

Abnormal constituents of the vaginal discharge, such as pus or 
blood, should be noted, also a bad odor or irritating qualities. (This 
subject is discussed at greater length in Chapter X., page 143.) 

Pain. — Pain in gynecological affections is generally situated in 
the inguinal and lumbro-sacral regions. 

Backache. — Backache is not characteristic of any special uterine 
disease and it may have no relation at all to the pelvic contents. 
All we can say is that it is very often present in women suffering 
with gynecological diseases. Backache is very common in women 
between the ages of thirty and fifty who are in a nervously run- 
down condition. One sort of backache due to sacro-iliac sub- 
luxation as described by Joel E. Goldthwait (Boston Med. and 
Surg. Journal, 1905, Vol. 152, 593) must be differentiated from 
rheumatism of the muscles in the lumbo-sacral regions. The sacro- 



PAIN 19 

iliac articulations are true joints and there is increased mobility 
in them as well as in the symphysis pubis in women during preg- 
nancy and during menstruation. In certain women, especially 
those having spinal curvature who are the victims of subluxation, 
only one sacro-iliac joint is tender to pressure, and the displace- 
ment is the cause of backache as well as referred pains in the hip, 
leg, and ankle on the same side as the loose joint, caused by 
pressure on the sciatic nerve. These symptoms are not limited to 
the time of pregnancy and labor, though exaggerated then. The 
symphysis pubis is generally a loose joint also in these cases and 
may be painful to the touch, especially during menstruation. The 
mobility and tenderness of all three joints should be tested in any 
case of backache. 

Muscular rheumatism is detected by tenderness on pressure of 
the following muscles: — the erector spina?, — the longissimus, — 
the sacro-lumbalis, or the quadratus, — and by pain caused by the 
use of any of these' muscles. When a patient with lumbo-sacral 
rheumatism starts to straighten up, there is great pain, which 
abates after a few minutes' use. A patient with this affection sits 
or lies preferably with the body bent forward. 

Coccygodynia is a painful affection of the coccyx and is charac- 
terized by pain between the folds of the buttocks and by tenderness 
on pressure applied to the tip of the coccyx. (See page 159.) 

Pain in the groins is common in uterine diseases. In acute 
pelvic inflammation it is generally pronounced, especially when the 
peritoneum is involved. In chronic uterine disease it may, or it 
may not, be present. If existent it is generally a dull, continuous 
pain. If on the right side it is to be differentiated from the sharp 
intermittent pain of appendicitis, and the pain and tenderness on 
deep pressure in this situation, in cases of uterine disease, are, as a 
rule, lower down than in appendicitis. 

A hearing-down feeling, or a sense of weight in the pelvis, is a very 
frequent complaint. If, in answer to your question, the patient 
states that she has pain, ascertain where it is situated; the point 
of greatest intensity; whether it is constant or intermittent, fixed 
or radiating; what sort of a pain, dull, sharp, or stabbing. Describe 
it in the patient's own words as far as possible. The relation be- 
tween the pain and menstruation, if any, should be inquired into; 
also the effect of exercise. The situation of the pain often shows 



20 INTERPRETATION OF THE CLINICAL HISTORY 

the nature of the lesion. Thus, pain in the sacral region may mean 
rectal disease, and pain above the pubes, disease of the bladder. 
This is not always the case, as is shown by the fact that disease of 
one ovary is often referred to the opposite side of the abdomen, 
therefore we must be on the lookout for referred pain. 

Abdominal swelling, indicating a tumor of any sort, is to be asked 
for. If present, when was it first noticed, — what is its exact situa- 
tion, — has it increased in size since it was first detected, and if so 
how much and how fast, — whether or no there has been pain in the 
swelling or tenderness on pressure. 

In the case of a suspected ovarian tumor, ask whether there has 
been a loss of flesh about the chest and shoulders coincident with 
the increase in the size of the abdomen. The occurrence of jaundice 
in connection with a tumor in the upper abdomen, as indicating 
disease of the liver or gall-bladder, is to be noted, also the relation 
between a tumor in the flank and impaired function of the kidneys, 
pointing toward tumor of the kidney. 

A swelling of the abdomen in a woman of child-bearing age may 
mean pregnancy, however improbable such a diagnosis may seem, 
— therefore ask always the date of the last menstruation. Bear 
pregnancy in mind even if the probable diagnosis is fibroid, 
ovarian cyst, or other tumor; pregnancy, intra- or extrauterine, 
may coexist as a complicating condition. It has happened 
several times in the author's experience that a surgeon of high 
reputation has discovered pregnancy in the course of an abdom- 
inal operation, undertaken for " abdominal tumor" without a 
more exact diagnosis. 

Bladder Symptoms. — The fact should be borne in mind that 
women, as a rule, urinate at less frequent intervals than men. In 
obtaining a history it is important to inquire as to the patient's 
habit as regards micturition, before drawing conclusions as to the 
abnormality of the symptoms. The occurrence of bladder affec- 
tions is rarer in women than in men. 

Frequency of urination on standing or exertion, with inability 
to hold the urine, may mean a stone in the bladder, whereas constant 
desire to urinate may be due to cystitis or urethritis; therefore it is 
necessary to inquire whether the frequency is by day or by night. 
Smarting on urination indicates some irritation of the" vulva or 
urethra. Inability to control the urine at all shows a fistula from 



THE BOWELS 21 

the bladder into the vagina, either directly, or by way of the uterus; 
lack of power over the bladder on laughing, sneezing, and coughing 
means lack of support to bladder or urethra from injury to the 
pelvic floor or to the anterior vaginal wall. These are samples of 
the class of facts which should be learned. (The subject is con- 
sidered at length in Chapter X., page 151.) Ask: — How often the 
patient urinates? How frequently at night? How much pain in 
the act? When the pain is most intense? How long the pain 
lasts? Is it possible to control the urine when the desire to urinate 
occurs? Is the trouble getting better or worse? Is it affected by 
menstruation? Is it better or worse when the bowels are free? 
When did the difficulty begin? What is the supposable cause? Is 
the trouble the same now as at the beginning? What treatment, if 
any, has been used? 

The Bowels. — Constipation is the rule in a large proportion of 
women suffering with gynecological affections. At least a third of 
all such patients are so affected, according to reliable statistics. The 
statement, however, that a woman is constipated does not describe 
the condition with sufficient minuteness. Many women pay little 
attention to their bowels, considering defecation as a troublesome 
function to be disregarded as long as possible. Therefore, it is 
necessary to make careful inquiries to determine that constipation 
really exists. The amount of fecal matter passed depends, of course, 
on the amount and character of food ingested. People of irregular 
habits as regards their food should be expected to pass a variable 
amount of fecal matter; four to eight ounces is said to be the 
normal amount passed in twenty-four hours if the patient is living 
on a mixed diet. The amount is more if the diet is vegetable rather 
than if animal. Habits of a lifetime have a controlling influence on 
defecation, and a person may evacuate the bowels regularly every 
other day or twice a day and yet be within the limits of the normal. 
We must inquire whether the bowels move regularly, i.e., without 
medicine, enema, or artificial aid of any kind, at stated periods of 
time, and what those times are; whether the action is full, or 
scanty, and the stools solid, semisolid, or liquid; whether there is 
pain on defecation at the time (hemorrhoids) or lasting after the 
movement (fissure of the anus); whether the stools are ribbon- 
like (stricture of the rectum) ; whether offensive (decomposition) ; 
containing blood, mucus, or pus (hemorrhoids or fistula in ano); 



22 INTERPRETATION OF THE CLINICAL HISTORY 

whether there is escape of gas involuntarily (some injury of the 
sphincter, or fistula in ano). 

In some cases of injury of the pelvic floor the patient finds that 
the only way she can evacuate the rectum is by making digital 
pressure in the vagina. Prolapse of the rectum on straining at 
stool is to be borne in mind in getting the history. 

Inquiry should be made as to the length of time constipation has 
existed, whether it is habitual or intermittent, and whether, in the 
patient's mind, there is any assignable cause. The physician should 
consider a pelvic tumor, rupture of the pelvic floor, a stricture, or 
malignant disease of the intestine as possible causes of constipation. 
(See Chapter X., page 156.) 

Present Illness. — Under this heading we group together the 
symptoms which go to make up the complaint for which the patient 
consults the physician. They consist of the data as to the functions 
of the different organs. Appetite, digestion, and sleep receive con- 
sideration in the detail justified by their importance in any given 
case, also any symptoms indicating derangement of the heart, 
lungs, kidneys, or other organs. 

Variations in the body weight are important as showing changes 
in the nutrition. Other things being equal, a greater weight shows 
increased vigor and strength; such a statement .being susceptible 
of modification in the case of very fat people. 

In this portion of the history the physician has an opportunity 
to show his ability as an internist and by his knowledge of the 
science and art of medicine to keep his patient, if possible, on the 
main line of practice instead of shunting her on to the sidetrack of 
specialism. 

It is always wise to note the exact date of the last menstruation 
before finishing the history. A habit of doing this will go a long 
way toward preventing awkward mistakes. 

Finally, as a matter of record, make a memorandum of the 
patient's peculiarities of form and figure. 



CHAPTER IV 

THE PHYSICAL EXAMINATION 

I. The preparation of the patient, p. 23. 

II. The preparation of the examining table, p. 26. Care of the instru- 
ments, with list of a full kit, p. 28. 

III. The examination: 1. Preparation of the physician and placing the 
patient on the table, p. 31; The dorsal position, p. 33. 2. Inspection of 
the external genitals, p. 33. 3. Palpation, p. 34: (a) The vaginal touch, 
p. 34; (6) The combined vaginal and abdominal touch, p. 38. 

Having taken the history as outlined in the preceding chapter, 
the next procedure is the physical examination. It is not neces- 
sary to follow exactly the same routine in all cases; nevertheless 
it is most essential to have a definite system and to proceed accord- 
ing to it in all but exceptional instances, because in this way, and 
in this way only, are sources of error, the omission of important 
signs, reduced to a minimum. 

First let us consider I. the preparation of the patient, then II. the 
preparation of the examining table and the instruments, and lastly 
III. the examination itself 

So much does a good diagnosis depend on careful preliminaries 
and on a multitude of little things that no apology is necessary for 
the space devoted to them. 

I. THE PREPARATION OF THE PATIENT 

It is absolutely essential that the rectum should be empty in 
order that the physician may make a satisfactory bimanual ex- 
amination, also, in the case of abdominal palpation, if the bowels 
are distended by feces or gas the ability of the examiner to appre- 
ciate the condition of the abdominal contents will be interfered 
with. Therefore the patient, if there is need and if time serves, 
should be instructed to take a cathartic the day before the exam- 
ination or an enema immediately before. 

23 



24 PHYSICAL EXAMINATION 

If a patient presents herself with the statement that the 
bowels have not moved for several days it is better not to 
make an examination until they are solvent, except in cases of 
emergency. 

Unless there is some suspicion of disease of the urinary organs 
the bladder is to be emptied just before the examination. In 
certain urinary cases, where it is desired to obtain a catheter speci- 
men of urine at the examination, the patient should be asked not 
to empty her bladder before the examination. 

As a rule it is better to have no douche or special wash given 
before the examination, because the examiner wishes to form an 
opinion as to the character of the discharge, if present. It is a 
simple matter for him to wipe away the discharge later with sterile 
cotton or some antiseptic solution. 

The most important matter in connection with the preparatory 
treatment of the patient and the one most often overlooked is the 
loosening of all constricting clothing about the waist. Simply to 
loosen the corsets and leave the drawers buttoned about the waist 
is not sufficient. So often women come to the examining table 
with corsets and skirts loosened, and investigation reveals one or 
two tight, constricting bands still left. Closed drawers should be 
removed. The union suit is a foe to an accurate diagnosis and 
should be removed. If the patient considers her condition of 
ill health important enough to consult a physician she should be 
ready to offer no hindrance to a proper examination. 

With any encircling girdle about the upper abdomen it is mani- 
festly impossible to compress the abdominal walls and to palpate 
the contents of the abdomen and pelvis. Such palpation is difficult 
enough with all conditions favorable, therefore do not handicap 
it by omitting to have all clothing loosened. 

If the patient is in bed she should be prepared by having her 
put on a fresh pair of stockings. Should the Sims position be 
used an extra towel will serve for covering the right thigh. 

Much depends on the physician's tact and the manner in which 
he goes about the preparation for the physical investigation. 
Women do not mind an examination which they consider necessary 
if the physician shows proper consideration for their feelings and 
knows how to go about the examination. If the matter is treated 
as disagreeable and to be put through as quickly as possible, the 



PREPARATION OF THE PATIENT 25 

result is apt to be that the physician's frame of mind will be re- 
flected in the patient and she will be ill at ease and consequently 
will not give herself up to the investigation, not relaxing the ab- 
dominal muscles and thus limiting the facts which may be gleaned 
through the tactile sense. 

The patient should be made to feel that the examination is to 
be conducted with as little pain and discomfort as is possible and 
that this is an important consideration to the examiner. She may 
be told a fact too often lost sight of, that pain, caused by roughness 
or vigorous handling, makes unconscious resistance and rigidity 
of the abdominal muscles, thereby dulling the sense of touch in 
the doctor's hands and preventing him from reaching deep-lying 
structures — consequently the examination is less successful. 
Often it is inadvisable to make a thorough investigation and a 
complete diagnosis at one sitting. Sometimes it is necessary to 
examine the patient on several different occasions before all the 
conditions have been found favorable and all the facts have been 
brought out. Therefore do not be led to express an opinion on 
the case prematurely. 

In the case of young girls it is generally advisable to use an 
anesthetic before making a local examination, although it is not 
always necessary, much depending on the nervous temperament 
of the patient. In making an examination of a virgin in whom 
menstruation has been established an anesthetic is seldom required 
if great tact and gentleness are used. It is far preferable to make 
the first examination without ether if possible, because often facts 
of importance, such as regions of tenderness, brought out during 
the examination, are lost in an ether examination, to say nothing 
of the unfavorable after-effects of the anesthetic on the patient. 
Should the first investigation show the need, another examination 
with ether can be made. 

Too much can not be said of the importance of the tactful hand- 
ling of the patient previous to the examination. To see one skilled 
nurse in a large hospital clinic put forty women on the table for 
examination during the course of an afternoon, no complaints, no 
objections, and one following the other with military precision, 
is an object lesson of no mean value. Few nurses acquire such 
expertness, and to few is it needful. Much may be learned by 
studying, when the opportunity offers, the way it is done. 



26 PHYSICAL EXAMINATION 

The local examination should be made during the intermenstrual 
period. Only in the case of hemorrhage and unusual conditions 
is it necessary to examine during menstruation. 



II. THE PREPARATION OF THE EXAMINING TABLE AND 
THE INSTRUMENTS 

Some hard surface on which the patient is to lie is a necessity 
for a proper examination. A soft bed or couch into which she 
sinks takes away all space under the buttocks for the unused fingers 
of the examiner's hand in the vaginal examination. Besides, most 
beds and couches are so low that the physician is in an uncom- 
fortable position while examining and so many of his muscles are 
tense that he can not concentrate his entire attention on what his 
fingers are feeling. Furthermore, with the patient on a low couch 
the physician can not get his eyes on a low enough level to look into 
the vagina unless he sits on the floor in an awkward and constrained 
position. 

A table, the size, shape, and height of an ordinary kitchen table, 
is on the whole the best surface on which to put the patient. Port- 
able or fixed supports for the feet are a useful addition and also a 
movable slide projecting from the right-hand lower corner of the 
table is a convenient adjunct. My table is stoutly built of walnut, 
has large casters on all four feet, and is of the following dimensions: 
— Length, 44 inches; breadth, 24 inches; height at bottom end, 
33 inches; height at head end, 31 inches. 

It is to be noted that the foot or examining end is higher than 
the head end. This is to cause the viscera to gravitate away from 
the pelvis and to allow of more pillows for the head without in- 
clining the trunk downward toward the pelvis. 

The table is covered with a hair pillow one inch thick, encased 
in a dark-colored, enameled canvas cover. This cover is buttoned 
to the under edge of the table top, as the removable sides of a 
carriage are fastened on. 

Fixed or portable rests for the feet are an advantage, because 
with the feet slightly elevated above the surface of the table and 
at a short distance beyond the table's edge the abdominal muscles 
are more thoroughly relaxed and the patient is more comfortable 



PREPARATION OF TABLE AND INSTRUMENTS 



27 



than she is with heels close to the buttocks, and slipping off the 
table. 

In private houses the kitchen table is always available or, if it 
is best in occasional instances to examine the patient in bed, an 
ironing board or bread board may be placed on the mattress under 
the patient's hips, which should be at the edge of the bed, the feet 
resting in two chairs. A folded blanket, or two thicknesses of a 
comforter, should be laid on the table or board to take away the 
hardness. In this way the patient is reasonably comfortable during 




Fig. 1. — The Examining Table. 



the short time occupied by the examination and the physician can 
do his work to the best advantage. 

There are few points of superiority and many disadvantages 
in the complicated and costly tables sold in the instrument shops. 
The patient is not at ease on an unstable surface and she does not 
like to feel that by the pressure of levers she may be tilted into all 
sorts of positions ; she is not in a state of mind to appreciate the 
beauty of the ingenious mechanism concealed in the table, and 
would rather lie on a solid, warm wooden table than on a hard, 
cold one, made of glass and iron. 



28 PHYSICAL EXAMINATION 

The ordinary vaginal examination need not be a strictly aseptic 
operation, and it calls for clean, not aseptic furniture. 

Suppose we have the table placed with its end toward a good 
light. We cover it with a folded comforter and a sheet, unless it 
is already provided with a permanent cushion. When the patient 
lies on her back with hips and heels at the edge, the only portion 
of the table which will come in contact with the region about the 
vulva and anus is a narrow part of the middle of the end, some 
two inches wide and six inches long. Therefore for every patient 
a fresh towel is opened just as it comes from the laundry and a 
newspaper is folded into it so that the original folds of the towel 
are reproduced. This towel, about six inches wide and a foot 
long, is now placed in the middle of the examining end of the 
table and one end tucked under the comforter or cushion. The 
surface to sit upon is thus some six by nine inches, according to 
the size of the towel. In this way each patient sits on an abso- 
lutely fresh towel, and the table is protected from the vaginal 
discharges or solutions used by the physician, by the newspaper 
which has been folded into the towel. 

It is seldom necessary to soil the sheet or cushion. If by any 
chance it is soiled, as in case of hemorrhage, the sheet or towel 
is removed and the enameled canvas surface of the cushion is 
washed and a fresh sheet or towel put on. A pillow for the pa- 
tient's head is placed at the head end of the table. 

Care of the Instruments 

Very few instruments are necessary for the routine gynecological 
examination. A uterine dressing forceps, a sound, and a small- 
sized bivalve speculum are frequently all that will be required. 

It is best to keep all instruments out of the patient's sight, 
because she does not admire them nor look at them from the same 
point of view as the doctor, and it is not at all reassuring to feel that 
all the bright instruments of seeming torture may be used on her. 

My full kit contains the following instruments: 

Flexible uterine sound; 

Uterine probe; 

Bozeman uterine dressing forceps; 

Uterine tenaculum, single; 






PREPARATION OF TABLE AND INSTRUMENTS 29 

Uterine tenaculum, double, or vulsellum ; 

Uterine scissors; 

Silver uterine probe ; 

Small-size Brewer bivalve speculum; 

Graves bivalve speculum; 

Smallest size Sims speculum, also No. 4 size; 

Eclebohls speculum (included in the kit for cases in which 
curetting or removal of a piece of tissue is necessary for diagnosis) ; 

Hunter vaginal depressor; 

Emmet curette forceps; 

Bozeman-Fritsch uterine douche ; 

Two uterine applicators; 

Uterine sharp curette with flexible shaft; 

Set of Hanks metal uterine dilators; 

Wart hen uterine dilator; 

Silver female catheter; 

Kelly meatus calibrator ; 

Set of Kelly double-ended steel urethral sounds; 

Kelly cystoscopes, Nos. 8, 10, 12; 

Alligator bladder forceps ; 

Two Kelly ureteral catheters; 

Kelly proctoscopes, two sizes; 

Kelly ureteral searcher, and rubber bulb and tube for suction ; 

Head mirror; 

Stethoscope ; 

Pelvimeter. 

Added to these are: 

Two sterile two-ounce bottles; 

Compressed tablets of cocaine hydrochlorate ; 

Sterile absorbent cotton; 

Sterile gauze; 

A bottle of creolin ; 

Cover glasses. 

A collapsible tube of a sterile, soluble lubricant sold under the 
names of Lubrichondrin, Glycerine Emollient, Muco, or K-Y 
Jelly. 

It is my practice to have one set of instruments in a drawer 
within easy reach of my right hand as I sit in front of my cxamin- 



30 PHYSICAL EXAMINATION 

ing table; another set is in a bag ready to be carried to consulta- 
tions at the patients' homes. 

After use the instruments are scrubbed with soap, hot water, and 
a nail brush, rinsed with boiling water, dried at once, and put away 
clean. In cancer cases and those in which infectious matter is 
pretty surely present the instruments are boiled in soda as well as 
scrubbed with soap and water before being put away. Before use, 
the instruments which it is thought will be used, are placed in a 
shallow enameled iron tray and boiled for five minutes in a one- 
per-cent solution of washing soda in water ; the soda solution is then 
poured off and hot water substituted. No instruments are ever let 
lie for any length of time after use without being washed. Until 
cleansed they are always kept immersed in water so that discharges 
and blood can not dry on. 



III. THE EXAMINATION 

1. Preparation of the physician and placing the patient on the 
table. 

2. Inspection of the external genitals. 

3. Palpation: (a) The vaginal touch. Dorsal position. 

(b) The combined bimanual vaginal and abdom- 

inal touch, including points in the anatomy 
and the findings on palpation. 

(c) The rectal touch. 

(d) The bimanual recto-abdominal touch. 

(e) Positions of the patient used in gynecological 

examinations other than the dorsal; the 
Sims position; the knee-chest position; the 
lithotomy position; the raised pelvis posi- 
tion; the standing position. 

4. Odor as a diagnostic sign. 

5. The collection of the discharges and tissues for bacteriological 
examination. 

6. Inspection of the abdomen. 

7. Palpation of the abdomen. 

8. Percussion, auscultation, and mensuration of the abdomen. 

9. Instruments and tteir use in diagnosis. 



THE EXAMINATION 31 



1. Preparation of the Physician and Placing the Patient 

on the Table 

The physician prepares himself by washing his hands 
carefully and if they are cold by warming them, and by 
pulling up the sleeves of his coat and his cuffs so that they 
will not come in contact with the patient. As to rubber cots 
and rubber gloves, they interfere with the tactile sense, how- 
ever used, and should be employed only in exceptional in- 
stances, as in cases of suspected gonorrhea and of fetid dis- 
charge, also in rectal examinations. They serve to protect 




Fig. 2. — The Examining Hand, Showing Protective Sleeve. 

coming patients and also the physician from contamination, as 
inoculation with syphilis, and favor the cause of asepsis. The 
physician who is personally neat and washes his hands care- 
fully before as well as after a vaginal examination, need have 
no fear of carrying bacteria from patient to patient. The 
examination can not be so well made with cots or gloves as without 
them, therefore do not use them unless necessary. 

As to protecting the sleeves, it is a good plan to wear sleeves 
made of "Stork sheeting" or thin rubber, with elastics at 
the wrists and elbows, pulled on over the coat sleeves. These 
rubber sleeves can be frequently cleansed and they prevent 
carrying infection from one patient to another. They obviate 
the necessity of removing the coat, a procedure which is undesir- 



32 



PHYSICAL EXAMINATION 



able because it seems to indicate to the patient formidable un- 
dertakings. 

Of the importance of washing the hands before the examination 
too much can not be said. One never knows what bacteria he 
may have on his hands and under his finger nails. Every one 
necessarily washes his hands after the examination; how much 
more essential, from the standpoint of the patient's safety, is the 
preliminary wash. He who would practice gynecology must have 
the handwashing habit. 

It is my custom to prepare a basin full of warm creolin solution, 




Fig 3. — The Dorsal Position. 

one per cent, and place it on the instrument table within reach of 
my right hand. As before stated, the examination is not and need 
not be a strictly aseptic operation; therefore some antiseptic, which 
docs not coagulate the albumen of the discharges, has an odor of 
its own, does not corrode instruments, nor irritate the tissues, is 
indicated. Any table will serve on which to lay the pan of instru- 
ments, basin, and sterile cotton. A low table is preferable to a 
high one. Its surface should be covered with a fresh towel. 
The usual position employed in gynecological examinations is 



INSPECTION OF EXTERNAL GENITALS 33 

the dorsal position. The Sims position, the knee-chest position, 
the elevated pelvis position, the lithotomy position, and the stand- 
ing position will be described later. 

The Dorsal Position. — Everything being in readiness, the patient 
steps into a hard-bottomed chair placed at the foot of the table 
and raises all her skirts behind, the physician meanwhile standing 
in front of her and holding up a sheet, so that she is screened from 
him as she sits on the little folded towel on the edge of the table. 
She lies down and puts her feet in the supports. To prevent 
straining the back it is well to ask the patient to draw up her knees 
as she lies clown, otherwise her back will reach the cushion while 
her feet are still in the chair, putting her into a sort of Walcher 
position, one of great discomfort. 

The sheet is now thrown over the recumbent woman so that 
she is entirely covered. Holding the lower edge of the sheet in 
the left hand the physician raises the patient's skirts in front with 
his right hand under the sheet. Then by carrying the middle point 
of the sheet upward to the pubic region both thighs are draped and 
only the vulva and anal regions are exposed. A woman does not 
object to an exposure of the genitals that is manifestly necessary 
so long as the surrounding parts and the body are covered up. 
This method of covering with the sheet is applicable to every sort 
of a case, and should be employed always unless the patient is 
anesthetized. 

If the examination is at the patient's home the table is prepared 
in a good light in her room and she either walks to the examining 
table, or, if unable to walk, is carried from the bed. 

2. Inspection of the External Genitals 

There is no valid objection to an inspection of the vulvar region; 
in fact, a proper diagnosis can not be made without it. The physi- 
cian seats himself in the chair used by the patient to get upon the 
table, and spreads a fresh towel over his knees. By placing the 
fingers of each hand on the labia majora the labia are drawn gently 
apart and he notes the condition of the hymen, whether with one 
or more openings, unbroken or broken ; the amount and character 
of the vaginal discharge; the appearance of redness about the 
orifices of Bartholin's glands or Skene's glands. 
3 



34 PHYSICAL EXAMINATION 

If redness appears about the orifices of Skene's glands, the well- 
anointed finger should be introduced for an inch into the vagina, 
pressing backward toward the sacrum with the dorsum of the 
finger as it is slipped into the vagina, and gentle pressure made 
with the tip of the finger along the course of the urethra from 
above downward to express pus from the glands. 

He notes further the condition of the meatus urinarius, whether 
closed or open; the prepuce, whether adherent to the glans clitoriclis 
or not, and injuries of the perineum. The surface of the perineum 
between the fourchette and the anus should present a convexity; 
if it is flat or concave it means an injury to the pelvic floor or 
perineum. 

Palpation is to be combined with inspection in determining the 
nature and extent of injuries in this region. (See Chapter XX, 
page 372.) One must be on the lookout for skin affections. Pedi- 
culi are occasionally found among the poorer classes; and all sorts 
of anomalies of the external genitalia are to be looked for. In- 
spection of the vagina will be taken up in the chapter on the use 
of instruments. 

3. Palpation 

Palpation includes the vaginal touch, the combined bimanual 
vaginal and abdominal touch, the rectal touch, and the combined 
bimanual recto-abdominal touch. The examination of the abdo- 
men will be considered in another chapter. 

(a) The Vaginal Touch. — The physician has washed his hands 
with care, his nails are always trimmed short and are clean, and 
his hands are warm. He stands facing the patient, who is in the 
dorsal position on the examining table. Now comes the question 
which hand to use for the vagina. I prefer the left hand for the 
reasons that the left hand is less frequently used for ordinary pur- 
poses than the right; therefore, the skin covering the terminal 
phalanx of the left forefinger is softer and capable of higher training 
of the tactile sense; less strength is required of the examining 
hand at the vagina than of the hand on the abdomen, which is 
engaged in gross manipulations, the right hand is usually the 
stronger except in the case of left-handed persons; the left hand 
is generally a trifle more flexible than the right hand, an important 



PALPATION 35 

consideration with reference to stowing away the unused fingers, 
and finally, using the left finger for the examination leaves free the 
highly trained right hand for the delicate manipulation of instru- 
ments. 

Whichever finger is chosen, that one should be used in all but 
unusual cases, because it is desirable to educate one finger to feel 
correctly. It is the exceptional physician who can become ambi- 
dextrous. 

Having decided on the left forefinger, it should be lubricated 
because the external genitals are dry, and pushing in the external 
parts causes the patient discomfort ; it is the skin which is in need 
of lubrication rather than the vagina, which is supplied normally 
with a lubricating medium, therefore anoint the external labia and 
these in turn will lubricate the finger. The best lubricant is some- 
thing of the nature of lubrichondrin, sold under the name of "muco- 
lubricans'' or "K-Y,' ; prepared from cartilage treated with heat, 
a mildly antiseptic jelly containing eucalyptol or gaultheria, or 
some other substance to give it a pleasant odor. It is soluble in 
water. It is kept in a sterile, collapsible tube and is free from all 
danger of contamination. The oils and vaseline are peculiarly ill 
suited for lubrication because they cling to the finger and instru- 
ments and are well adapted to receive, retain, and distribute patho- 
genic organisms. Soaps are irritating to many patients, particu- 
larly in inflammatory conditions of the external genitals. The 
physician squeezes from the tube an ample quantity of lubri- 
chondrin on to the dorsal aspect of his forefinger, anointing only the 
terminal and second phalanges. By bringing the hand downward 
until the little and ring fingers touch the table just under the cleft 
of the buttocks, the tip of the anointed forefinger seeks the perineum. 
When it is reached the back of the bent forefinger is drawn upward 
over the fourchette, thus lubricating the labia and the vestibule, 
the knuckle falling into the depression at the introitus vagime. 
A second sweep with the finger, it is straightened, and the tip settles 
into the vagina. It is to be noted that the lubricant has been put 
only where it is needed and that there is none on the unused hand 
and on the patient's linen. 

In introducing the finger into the vagina one bears in mind the 
condition of the hymen as noted at the previous inspection. If 
the hymen is tight great gentleness should be used and sufficient 



36 PHYSICAL EXAMINATION 

time allowed for dilatation. Room in the vagina is always to be 
gained by pressing backward toward the sacrum, as the perineum 
and pelvic floor are dilatable in this direction only. The structures 
which hug the under surface of the pubic arch, the clitoris, vestibule, 
anterior vaginal wall, and urethra should be avoided as far as 
possible, as in that region sensation is most acute. 

The examining finger may be likened to a small speculum as it 
carries down the perineum and opens the vagina. In many cases 
it is possible to use the finger in the place of a speculum. 

As soon as the middle knuckle of the examining finger has passed 
the hymen the hand is turned so that the thumb is upward. The 
three unused fingers are carried behind the anus in the cleft of the 
nates and the thumb is moved to the left or right of the median 
line out of the way of the clitoris. The perineum and pelvic floor 
can be pushed in to a variable extent by the web between the 
index and middle fingers and thus the examining finger reaches 
farther. It is seldom necessary to employ two fingers for the 
vaginal examination, although there are cases where more may be 
learned with two than with one. The palmar surface of the last 
phalanx of the forefinger is the chief seat of the trained tactile 
sense. As a rule, particularly in virgins, two fingers cause the 
patient a great deal of discomfort and therefore accentuate the 
disagreeable features of the examination, tending to distress of 
mind and body and consequently preventing the relaxation so 
essentia] for a successful investigation of the contents of the pelvis. 
The scope of the vaginal touch depends, in a measure, on the ana- 
tomical peculiarities of the examiner's hand. A physician having 
thick, chunky hands with short fat fingers can not hope to be as 
good a gynecological diagnostician as one having a slim hand with 
long, tapering fingers. In women of spare build who have borne 
children, practically the entire inner surface of the pelvic cavity 
may be palpated by a long finger or fingers introduced into the 
vagina. It is not unusual to touch the promontory of the sacrum 
and the sacro-iliac synchondroses, besides all parts of the pelvic 
floor, not to mention the structures occupying the pelvis. (See 
Fig. 4.) 

The examining finger as it enters the vagina notes the following 
points: — The state of the hymen, whether with large opening or 
small, whether rigid or easily dilatable ; the vaginal walls, whether 



PALPATION 



37 



with rugae or smooth, whether of normal temperature, or hot, as 
in the case of inflammatory affections of the pelvic organs, or in 
fevers; whether the walls of the vagina are in apposition, or lax 
or separated; the amount of secretion, a dry vagina giving an en- 
tirely different sensation from a moist one; the condition of the 
pelvic floor and perineum; in the case of a parous woman search 
for a groove in either sulcus or the middle line, remembering the 
normal conformation of the perineum, that is to say, a convex 
surface in the vagina as well as on the skin outside; sometimes it 
is well to introduce the well-anointed forefinger of the right hand 
in the anus and palpate the tissue lying between the two 




Fig. 4. — Half a Female Pelvis, with Hand in Position as for Vaginal 

Examination. 

fingers in order to get a correct idea as to injuries which may 
be present. The vaginal touch informs us as to the contents of 
the rectum, whether empty or containing hard fecal masses, semi- 
solid feces, or dilated by fluid or gas; also whether or no the blad- 
der is distended. 

In order to practice this sort of palpation successfully re- 
quires a long experience and a thorough familiarity with the 
normal conditions, also the variations of the normal in different 
individuals. 

Abnormalities of the vagina are to be detected by touch; such 
are cysts, partial septum, narrowing of the lumen by cicatrice-, 



38 



PHYSICAL EXAMINATION 



the sequelae of old inflammatory action, or from congenital defects 
of development; also roughness, as in granular vaginitis. 

On palpating the anterior wall of the vagina the urethra is felt, 
and thickening or sensitiveness of this structure — evidences of 
inflammation — are detected. So also the base of the bladder is to 
be touched to determine thickening or points of tenderness, in- 




Fig. 5. — Diagrammatic Drawing, Illustrating the Bimanual Touch. 

dicating the situation of ulcerated areas in the bladder mucosa. 
The ureters when thickened are easily palpable running from the 
bladder base toward the sacro-iliac synchondroses. The upper 
course of the pelvic portion of the ureters can be best detected by 
rectal examination. 

(6) The Combined Bimanual Vaginal and Abdominal Touch. — 
When the tip of the examining finger reaches the posterior 



PALPATION 39 

fornix of the vagina the physician's right hand is laid gently 
on the lower abdomen, palm down with the heel of the hand 
just above the symphysis pubis. Very gentle and slowly applied 
pressure is made with this abdominal hand, all sudden movement 
being avoided as calculated to excite pain and consequently 
resistance of the abdominal muscles. The balls and not the tips 
of the fingers are used. The pelvic organs are carried down by 
the pressure above until they are within reach of the finger in 
the vagina, and conversely they are raised by the finger below 
until within touch from above. In the case of the bimanual 
vagino-abdominal touch we hold between our hands (the finger in 
the vagina and the hand on the abdomen) the contents of a box, 
the cavity of the pelvis. 

It is sometimes a help in making the bimanual examination for 
the physician to rest the elbow of the hand making the vaginal 
touch on the knee of the corresponding leg, his foot being placed 
on the chair which is close to the table. 

Factors outside of the condition of the bowels and rectum 
limiting what can be felt by the bimanual touch are, the amount of 
adipose tissue present, and the rigidity or laxity of the muscles 
of the abdominal walls. A rigid perineum has been referred to 
already as lessening the amount of invagination of the pelvic floor 
that may be made by the web between the fingers of the hand at 
the vulva. 

In fat women both the vaginal and bimanual touch are in- 
terfered with. Other things being equal, it is impossible to 
make as accurate a diagnosis in a fat woman as in a thin woman. 
The fat in the perineal region reduces the scope of the vaginal 
touch. A greater hindrance is the fat in the abdominal walls; 
with two or three inches of fat in the panniculus adiposus the 
tactile sense is much blunted. It is like feeling through six or 
eight thicknesses of blankets. Naturally, then, we do not hope 
to make as good a diagnosis as when the abdominal walls con- 
tain little fat. 

A rigid abdomen is a bar to diagnosis by touch. One can feel 
very little through a stiff sheet of pasteboard. If there is present 
peritonitis or great sensitiveness of the abdomen from any cause 
we expect to find rigidity. Many patients become rigid through 
anxiety and fear of painful manipulations by the physician, others 



40 PHYSICAL EXAMINATION 

reflexly because of the discomfort caused by the laying on of the 
hands. Therefore, not only is the utmost gentleness imperative, 
but also it is a matter of supreme importance not to arouse the 
patient's fears by brusk behavior, or by the uncalled-for display 
of instruments. 

As to gentleness, the flat hand on the lower abdomen makes 
light pressure and the physician inquires whether it causes 
pain. Distracting the patient's attention by a question or two 
often prevents rigidity. Next, the hand is arched by flexing 
slightly all the fingers so that the balls of the fingers press in 
deeply. It is very essential not to make the tips of the fingers 
press, the same rule holding here as in massage. Make pressure 
with the palmar surface of the last phalanges, for the tips of 
the fingers and the finger nails cause pain, and, also, less can be 
felt with the tips. 

Ask the patient to take a long breath; as she does so, gently hold 
the abdominal wall in. Repeat the process and the examiner's 
hands are brought nearer and nearer together with each expiration. 
Judgment is necessary in performing this maneuver because too 
rapid or too forcible pressure will cause the abdominal muscles to 
contract, thus defeating the objects of the examination. Assist- 
ance is gained in some rare cases by drawing down the cervix 
with a tenaculum held by an assistant. In this, way the back of 
the uterus and the broad ligaments are reached and also tumors 
and other attachments are made out. 

The bimanual or conjoined examination is the keystone of the 
gynecological diagnostic arch. Nothing takes the place of the 
trained touch, and it is doubtful whether, in the march of progress, 
any form of investigation will supplant it. 

Specula for the vagina, the bladder, and the rectum, bacteriology, 
and the microscope with its findings as to the nature of the blood 
and tissues, and the x-rays, detecting a stone in the bladder, 
ureter, or kidney, all have their uses. The bimanual touch is the 
most important. 

The finger in the vagina notes, first, the situation, size, conforma- 
tion, consistency, and sensitiveness of the cervix; lacerations, 
their location and extent ; whether or no the tissues of the cervix 
are of normal consistency, or soft as in septic conditions or after 
labor, or indurated as in chronic metritis. The friable, bleeding 



PALPATION 41 

cervix of cancer is rarely mistaken for any other condition, except 
possibly a sloughing, pedunculated fibroid. 

Cysts of the Nabothian follicles can be diagnosticated as 
shot-like bodies; a stringy, tenacious plug of mucus in the os 
can be differentiated from a thin discharge; in rare cases the 
cervix may be out of reach, being forced upward into the abdomen 
by a tumor in the pelvis so that it may lie on a level with the 
upper border of the symphysis pubis; the different situations of 
the cervix in the various malpositions and malformations of the 
uterus will be considered in the chapter devoted to these diseases. 
The long conical cervix found especially in pathological ante- 
flexion, so called, is readily distinguished from its opposites, the 
apparently short cervix — one in which the vagina has been 
stripped by childbearing from its attachments to the portio, or 
from the really short senile cervix. 

The pinhole os is differentiated by touch from the os tincse. 
By the vaginal touch we detect a polypus projecting from the os 
uteri. In the case of large polypi we detect the location and size 
of the pedicle by sweeping the finger about the tumor and noting 
where and how it is attached. Sensitiveness of the cervix to light 
pressure indicating endocervicitis is to be sought for. A prolapsed 
ovary or tube may be felt on one side of the cervix and an excursion 
to one of the sacro-iliac joints may, in rare cases, detect tenderness 
and induration there. 

Palpating the normal ovary by the bimanual touch is a difficult 
matter unless all the conditions are favorable. These are, a patient 
with thin and relaxed abdominal walls and an injured perineum. 
Under such circumstances the ovary may be rolled between the 
fingers of the examiner's hands. Whenever the ovary is enlarged 
from any cause its palpation is rendered easier. In the case of 
rigid abdominal walls, large deposits of fat in these structures, a 
tight hymen and unyielding perineum, the palpation of the ovary 
becomes difficult. Often only the under surface can be felt, and 
sometimes only by a rectal examination. Note the sensitiveness 
to pressure of the normal ovary and in the case of a diseased ovary 
inquire of the patient if the pain caused by pressure is the same as 
that suffered at other times. 

The Fallopian tube can not be felt by bimanual examination 
unless it is thickened or enlarged by disease. In this event it 



42 



PHYSICAL EXAMINATION 



may be mapped out with varying degrees of exactness according 
to the condition of abdominal wall and perineum. 

An abscess in the pelvis, whether originating in the tube, the 
ovary, the vermiform appendix, the sacro-iliac joint, or coming 
from above in the psoas muscle, may be mapped out by the bi- 
manual touch and a point of fluctuation found if it exists. 



CHAPTER V 

THE PHYSICAL EXAMINATION (Continued) 

III. The examination (continued) — 3. Palpation (continued) : Anatomy 
of the pelvic contents, p. 43. Barriers to infection, p. 43. Mobility of the 
uterus, p. 44. The uterine ligaments, p. 44. Mechanics of the pelvic and 
abdominal contents, p. 44. The pelvic circulation, p. 46. The normal 
position of the uterus, p. 49. Structures to be distinguished by palpation, 
p. 49. Inferences to be drawn from palpation, p. 50. (c) The rectal touch, 
p. 50. (d) The recto-abdominal touch, p. 53. (e) Gynecological positions 
other than the dorsal position, p. 53: The Sims position, p. 54; The knee- 
chest position, p. 56; The lithotomy position, p. 57; The raised pelvis 
position, p. 58; The standing position, p. 59. 

4. Odor as a diagnostic sign, p. 60. 

5. The collection of the discharges and tissues for microscopic examina- 
tion, p. 61 : Bartholin's glands, p. 61. Skene's glands, p. 61. The 
cervical canal, p. 62. The preservation of tissue, p. 63. 



III. THE EXAMINATION (Continued) 
3. Palpation {Continued) 

Before describing further the pathological conditions which 
may be diagnosed by the bimanual touch, it will be well to review 
some points in the anatomy, physiology, and mechanics of the pelvic 
organs. No attempt will be made to give a complete description 
such as may be found in text-books of anatomy. 

Think of the pelvis as a box, closed below by a flexible diaphragm, 
the pelvic floor, and open above into the abdominal cavity. Direct 
communication between the pelvic cavity and the outside world 
is established through the lumen of the Fallopian tubes, the uterine 
cavity, and the vagina. The barriers to the entrance of infective 
bacteria to the peritoneum are (1) the narrowings of the canals 
at the isthmus of the tube, the internal os of the uterus, and the 
hymen, and (2) the downward current of the secretions, partially 
maintained by the cilia of the lining epithelial cells, partly by 
peristalsis of the tube, and also by coughing and straining. 

43 



44 



PHYSICAL EXAMINATION 



The uterus occupying the center of the pelvic cavity is suspended 
with its long axis coinciding with the long axis of the pelvis and at 
right angles to the long axis of the vagina. An important point 
to remember is that it is suspended and oscillates every time its 
owner coughs, sneezes, laughs, or moves about. It is held in place 
by certain ligaments to which it is attached, by its connection with 
the vagina, by the pelvic floor supporting the vagina, and by the 
pressure of the abdominal contents. 

The ligaments are folds of peritoneum containing connective 
tissue, vessels, and nerves, and, in the case of the round and utero- 




Fig. 6. — Vertical Median Section of Body. (Kelly.) 

sacral ligaments, a few muscle fibers. The broad ligaments are 
on both sides with long attachments to the sides of the uterus, 
thick at their lower portions, reaching from the cervix nearly to the 
fundus and attached at their other ends to the sides of the pelvis. 
At the back are the utero-sacral ligaments, attached to the posterior 
surface of the uterus at the region of the internal os and extending 
to the back wall of the pelvis at the level of the second or third 
piece of the sacrum. The utero- vesical connective tissue is in front 
and also the round ligaments, which begin as large fleshy cords 



PALPATION 



45 



just in front of each horn of the uterus and extend to the internal 
abdominal rings, becoming smaller and smaller as they approach 
their insertion in the fat of the pubes. 

It is to be noted that when a woman is in the erect position (see 
Fig. 6) the insertions and origins of the round ligaments lie 
practically in the same horizontal plane, therefore these ligaments 
act rather as steadying guys than as supports to the uterus. In 
the case of the broad ligaments they are thick and strong in their 
lower portions and really support the cervix. So also the utero- 
sacral ligaments support the lower uterine segment and through 
it the upper vagina. The attachments of the vagina to the cervix 
serve to steady this portion of the organ and keep it in its proper 
relation to the pelvic floor. The supporting 
action of the pelvic floor will be found de- 
scribed in more detail in the section on pro- 
lapse, Chapter XIV, page 220. 

The abdominal cavity may be likened to 
an upright cylindrical vessel filled with water 
and closed at both ends by an elastic mem- 
brane. The weight of the water causes the 
bottom membrane to bulge outward and the 
pressure of the atmosphere the top membrane 
to sink inward. 

In the case of a living woman, standing 
erect, the diaphragm represents the top mem- 
brane, the pelvic floor the bottom membrane, 

i « c i ii i i ii FlG - 7 -~ A Vertical 

the walls of the abdomen the vessel, and the Cylinder closed at either 
liver, stomach, spleen, kidneys, pancreas, in- End by an Elastic Dia- 
testines, and uterine organs the fluid. The P hragm and Filied with 
posterior wall of the abdomen is practically 

immovable like the walls of the tube, but the anterior wall is elastic 
and capable of varying within wide limits, not only the capacity of 
the abdominal cavity, but the pressure exerted on its contents. 

The contents of the abdominal cavity are solid, fluid, and gaseous, 
and the different structures are stowed so closely together that 
there is no waste space between them. The pressure which can 
be exerted on a solid organ in the abdominal cavity such as the 
liver, has no effect other than to compress it slightly or cause it to 
move within the limits permitted by its suspending ligaments. 




46 PHYSICAL EXAMINATION 

According to a law of physics, pressure on the fluid contents of a 
closed vessel is transmitted with equal intensity in all directions. 
Pressure on the gaseous contents has no other effect than slightly to 
lessen their volume. The abdominal organs are supported by their 
ligaments and mesenteries, by each other, by the abdominal walls, 
— the upper ones by the ribs, — by the anterior projecting lumbar 
spine, and by the shelf of the false pelvis covered by the psoas 
muscles. (See Fig. 86, page 221.) Therefore, when the woman is 
in the erect posture the weight of the abdominal contents, minus 
what is assumed by the mesenteries and the abdominal walls, rests 
on the anterior face of the lumbar spine and the slanting brim of 
the false pelvis, on the lower anterior abdominal wall, and also on 
the posterior surface of the uterus and the broad ligaments and 
through them on the pelvic floor. Increased pressure due to con- 
traction of the abdominal walls, straining; or downward excursion 
of the diaphragm, coughing and sneezing; is transmitted to the 
fluid contents in all directions. The posterior walls of the abdomen 
are rigid, the anterior walls are rigid when contracted, the bony 
wall of the pelvis is rigid, the pelvic floor is elastic, therefore it 
bulges downward, like the membrane on the bottom of the vessel 
in the figure. 

If instead of being in the erect posture the woman is in the 
knee-chest position, the conditions are reversed. Now the weight 
of the abdominal contents comes on the diaphragm and the upper 
front walls of the abdomen, the pelvic floor is depressed inward 
like the upper membrane covering the vessel ; when the vagina, rec- 
tum, or bladder is opened, air rushes in to replace the negative 
pressure, thus maintaining the equilibrium of the atmosphere, 
fifteen pounds' pressure to the square inch exerted in all directions. 

In this connection the pelvic circulation is to be considered. 
Emmet pointed out long ago (Trans. Amer. Gyn. Soc, 1887, Vol. 
XII., p. 65) that the veins of the pelvis are without valves, and 
to overcome the effect of gravity their course is extremely tortuous. 
"Moreover, this provision is necessary that undue traction be 
not made upon the vessels with the change of position, and with 
the increasing bulk of the uterus depending upon gestation." He 
noted the fact that if we draw down a healthy uterus to a certain 
point near the floor of the pelvis and hold it there, the cervix and 
vaginal mucosa become congested very soon, as evidenced by the 




47 



48 



PHYSICAL EXAMINATION 



dark color of the tissues, denoting venous congestion due to straight- 
ening out of the tortuous arteries and veins. 

If the traction is continued until a portion of the uterus projects 
from the vagina, the tissues become blanched. This is thought 
to be due to a stretching out and a lessening of the caliber of the 
arteries so that the blood supply is cut off. The connective tissue 




Fig. 9.— The Contents of the Pelvis from Above. (Kelly.) 

of the pelvis is as the trellis to the grape-vine, the pelvic fascia 
serving as a firm support for the whole. 

On each side of the uterus are the ovaries floating, as it were, 
on the posterior surface of the broad ligaments, and the Fallopian 
tubes extending from both sides of the fundus uteri to the outer 
extremities of the ovaries. The ovaries and the fimbriated ends 
of the tubes are steadied at their outer ends by the infundibulo- 
pelvic ligaments, otherwise their movements are regulated by the 



PALPATION 49 

movements of the uterus, broad ligaments, and the abdominal 
contents. 

The bladder, when filled, pushes the uterus and the ovaries and 
the tubes backward, tending to cause retroversion. The rectum, 
occupying the left posterior portion of the pelvis, when distended 
tends to raise the uterus and also makes for retroversion, because 
limiting the backward excursion of the cervix. 

It is plain, then, that the normal position of the uterus varies 
somewhat according as the woman is standing or is lying down, 
it being somewhat more anteverted in the former and less ante- 
verted in the latter, because of the effect of gravity and the vary- 
ing pressure of the abdominal contents on the fundus. Also its 
position as well as its mobility varies according to the state of 
fullness of the bladder and the rectum. 

In practicing bimanual palpation the following structures are to 
be felt: the symphysis pubis; the promontory of the sacrum; the 
uterus; the ovaries; the Fallopian tubes, when diseased so that they 
are thickened or enlarged ; the appendix vermiformis, very excep- 
tionally and only when thickened or enlarged by disease; the rectum 
and bladder, only, as a rule, when their walls are thickened. 

In rare cases having lax and thin abdominal parietes a thick- 
ened ureter may be palpated at the point where it crosses the 
pelvic brim just outside the internal iliac artery and the sacro- 
iliac joint. A thickened ureter may be felt always for two inches 
or so after it leaves the bladder. In favorable cases the normal 
ureters may be palpated per vaginam, but this is a fine point and 
not an accomplishment of many physicians. 

On making downward pressure on the abdomen the promontory 
of the sacrum is felt just below the level of the umbilicus. Midway 
between the promontory and the symphysis pubis, or a trifle nearer 
the symphysis, the fundus uteri, if normally placed, is to be made 
out. In the erect posture the external os uteri is on a level with 
the upper margin of the symphysis pubis; in the recumbent at- 
titude the os is slightly higher. 

Steadying the cervix with the vaginal finger the examiner moves 
the uterus up and down and from side to side, thus gaining an 
idea of the mobility, whether normal or limited by past or present 
inflammatory action in the surrounding tissues, or by a tumor or 
a full bladder. 

4 



50 



PHYSICAL EXAMINATION 



The uterus may be displaced as a whole downward in the axis 
of the pelvis (prolapse), or backward (retroposition) , or excep- 
tionally upward. Alterations in the axis constitute retroversion 
(often made to include retroposition) and anteversion. Lateral 
versions are of little importance. 

Besides the situation, axis, and mobility of the uterus, one notes 
its form (abnormalities, flexions, and tumors), its size (atrophic 
or hypertrophic), and its density (soft in pregnancy and septic 
conditions and hard in chronic inflammation and in many tumors) » 




Fig. 9a. — Normal Female Pelvis. 

Pressure on the uterine body eliciting tenderness denotes en- 
dometritis; and tenderness of the cervix, endocervicitis. 

Tumors anywhere in the pelvis are to be placed accurately, and 
their size, form, consistency, and sensitiveness to pressure de- 
termined, also their relation to the pelvic organs. This relation 
is established often by moving the tumor and noting if the uterus 
moves, or vice versa. 

In acute pelvic inflammation the abdominal walls are apt to be 
rigid because of the peritonismus which is generally present. Under 
these conditions little can be learned except by the vaginal touch. 

Exceptionally it is best to combine instruments with the bi- 
manual touch as described in Chapter VII. 

(c) The Rectal Touch. — This method of examination is resorted 
to in order to gain a slightly higher reach in the pelvis and also in 



PALPATION 51 

cases where it is inadvisable to make the vaginal touch, as in 
young girls, a virgin with a rigid hymen, the case of a narrow, 
shallow vagina, or a congenital or acquired atresia of this organ. 

In making a rectal examination it is desirable to use a large 
amount of lubricant because of the tightness of the anus. The 
digital examination of the rectum causes much more discomfort 
to most women than the digital examination of the vagina. There- 
fore, every reasonable device should be employed to lessen the 
discomfort, and also, unless the finger is well lubricated, the anus 
will grasp it so tightly as to interfere with its tactile sense. It is 
well to use a thin rubber cot for the rectum, removing it as soon as 
this part of the examination is over. Before making the examina- 
tion the anal region is smeared freely with muco-lubricans and the 
left forefinger is thoroughly anointed as well. 

Sometimes in patients who are annoyed by an accumulation 
of gas in the rectum it is well to let this gas out before making the 
examination, by passing a catheter through the anus before in- 
troducing the finger. As a rule, however, the presence of gas in 
the rectum facilitates the examination. The vaginal touch, if 
it has preceded the rectal touch, will give an inkling as to the 
condition of the rectum. The presence of fecal matter calls for 
an enema. 

In passing the finger through the anus, note the tonicity and 
strength of the sphincter ani. In the case of hemorrhoids or 
fissure, where there has been long-standing irritation with consequent 
increased muscular action, the sphincter will be found in many 
cases to be hypertrophied. The sphincter may be weak and 
insufficient because of injury received during childbirth or by over- 
stretching at the hands of a surgeon, or in cases of rectal prolapse 
or atrophic catarrh. 

A fissure by presenting a localized point of sensitiveness, hem- 
orrhoids by giving a feeling of lumps in the rectal wall, and also 
polypi by their feeling of pedunculation, may be detected by 
touch. The situation of the opening of a fistula in ano into the 
bowel can not be determined without the aid of a probe. Through 
the thin anterior rectal wall the examining finger makes out the 
cervix, the bases of the broad ligaments, and the utero-sacral liga- 
ments. By raising the uterus, these ligaments are put on the 
stretch and an idea may be obtained as to their relative length 



52 



PHYSICAL EXAMINATION 



and thickness. The posterior wall of the uterus is very accessible 
through the rectum. 

The ovaries and tubes if prolapsed may be palpated advanta- 
geously by the rectal touch. 

Through the posterior wall of the rectum the coccygeal and 
sacral vertebrae may be felt, and fractures and dislocations of the 
coccyx determined. Pain caused by pressure on the coccyx may 
mean coccygodynia. (See Chapter X., page 159.) 

Infiltrations or new growths in the recto- vaginal septum are 
to be mapped out, as to size, situation, consistency, and sensitive- 




Fig. 10. — Half a Female Pelvis, Showing Accessibility of Contents to Palpation. 

ness, by combined vaginal and rectal touch, the finger of one hand 
being in the vagina, and the forefinger of the other hand in the 
rectum. The presence of new growths and strictures in the 
rectum is diagnosed by the rectal touch. 

Too great care can not be exercised in washing the hands before 
changing from a rectal to a vaginal examination and vice versa, 
because of the danger of transferring infective matter from one organ 
to the other. In the case of acute infective inflammation of the 
vulva and vagina, it is wiser not to examine the rectum at all. 
Often the rectal examination may be deferred as well to a later date. 



PALPATION 



53 



By the rectum it is possible to palpate the branches of the sacral 
plexus of nerves where they course along the sides of the pelvis, 
and also to palpate a psoas abscess or disease of the sacro-iliac 
articulation. 

(d) The bimanual recto-abdominal touch is the same as the 
bimanual vagino-abdominal touch as regards the structures which 
are reached, except that greater opportunity is generally afforded 




Fig. 11. — The Sims Position. 



for exploration of the cul-de-sac of Douglas and its contents, than 
by the bimanual vagino-abdominal touch. 



Digital exploration of the bladder is an unjustifiable procedure, as 
all the information obtained by touch may be gained by a speculum 
examination and by vaginal and rectal touch. The danger of 
incontinence of urine is too great to justify introducing the finger 
through the urethra, no matter how small the finger may be. 

(e) Gynecological Positions other than the Dorsal Position. — 
Besides the dorsal position which has been described already, there 
are several other positions into which the patient is put for pur- 
poses of examination. 



54 



PHYSICAL EXAMINATION 



They are: — the Sims, the knee-chest, the lithotomy, the raised 
pelvis, and the standing positions. 

The Sims position is not so frequently used now as in the years 
following the invention of the Sims speculum. Still, it is of great 
service both for the use of the speculum and other instruments, 
for practicing the bimanual touch , and for examination of the anus 
and rectum. For some reason not altogether clear, the illustra- 
tions introduced into all but one or two text-books on gynecology 
to show this position, do not figure it correctly as it was devised 

by Sims or as it is used in 
the hospital where he did 
his work, the Woman's 
Hospital in the State of 
New York. As commonly 
shown, the patient is lying 
on her left side with thighs 
only partly flexed on the 
abdomen, in the middle of 
a long table; her head is 
generally on the left side 
of the table, her hips in the 
middle, and so far from the 
bottom edge that the gen- 
itals are entirely inaccess- 
ible for examination. 

Suppose we have finished 
with the dorsal position 
and wish to put our patient 
in the Sims position. Pull- 
ing the sheet off and holding it in front of her we give her a hand 
and ask her to stand in the chair at the foot of the table. Then 
we pull out the little slide for a foot rest in the right-hand lower 
corner of the table and place the pillow for the head diagonally 
about midway along the right edge of the table. Now we ask her 
to raise her skirts and to sit on the left-hand corner of the table, 
sitting as far over to the left as she can and turning on her left 
side and drawing up her knees as she lies down. Throw the sheet 
over the hips as soon as she gets down. Next ask her to put her 
left arm over the left edge of the table and help her to do it. 




Fig. 12. — Diagram of the Sims Position. 



PALPATION 55 

See that her head is on the pillow on the right side and that she 
is, as it were, doubled up like a jack-knife. Then the physician 
stands on the left of the table facing the patient's hips, pulls them 
(asking at the same time for the patient's assistance) to the left, 
until the back of the sacrum is even with the left edge of the table, 
and the lower margin of the buttocks corresponds with the lower 
edge of the table. The feet are now on the foot rest, or, in 
default of this, on the back of a chair padded with a folded blanket, 
or on a table. The upper, the right knee is advanced a little 
be3'ond its fellow, and the inner edge of the sole of the right foot 
rests on the instep of the left foot. 

A fresh towel opened out is made to cover the lower buttock 
and thigh by tucking one end into the drawers behind, and carry- 
ing the other end between the thighs in front. The free end below 
is tucked under the covering of the table. The upper buttock 
and thigh, the legs and feet, and the rest of the body are covered 
by the sheet. 

In this position the pelvis is inclined at a slight angle to the 
table, the abdominal contents fall away from the pelvis, leaving 
the pelvic organs free from pressure; the abdominal walls are 
relaxed and the vagina, ballooned by air admitted by the speculum, 
can be most easily inspected. 

It is difficult to put very stout women, or patients with large 
abdominal tumors, in this position and in these cases the Sims 
position is of less value than in thinner subjects. 

The important points are to get the patient's back on a level 
with the left edge of the table and the head on the right edge of 
the table. Unless the patient is put in the correct position it is of 
no value whatever. Unless the thighs are sharply flexed on the 
abdomen and the hips are at the edge of the table, the physician 
can neither look into the vagina nor make manipulations to ad- 
vantage. 

The bimanual vagino-abdominal or recto-abdominal touch is 
made with the patient in the Sims position by introducing the left 
forefinger in either vagina or rectum and the right hand between 
the thighs, asking the patient to raise her right thigh until the hand 
is in place and then letting it drop again. 

The Sims position is useful also for palpating uterine and ova- 
rian tumors: with the patient in this position, relaxation of the 



56 PHYSICAL EXAMINATION 

abdominal walls may be obtained often, when it can' not be with 
the patient in the dorsal position. 

The knee-chest position, or knee-elbow position, as it is some- 
times called, is another gynecological position commonly wrongly 
figured in the text-books. The patient stands in the chair at the 
foot of the examining table facing the table. She raises her skirts 
in front and places one knee near one corner of the table, the other 




Fig. 13.— The Knee-Chest Position. 

knee follows and takes its place at the opposite corner of the 
table. Then she bends forward and places her hands in the middle 
of the table while the physician throws the sheet over her. The 
feet and legs are left projecting over the table's edge, but the 
position is not uncomfortable, for all the weight comes on the 
knees and hands. Now the patient is on her hands and knees on 
the table. The physician folds a good-sized pillow once and 



PALPATION 57 

places it in the middle of the table. The patient is asked to place 
her head and chest on the pillow with her face to one side, letting 
herself down on to her elbows as she does so. The physician next 
goes to the foot of the table, throws the skirts above the hips 
under the sheet and drapes each thigh with the sides of the sheet. 
Note now whether the thighs are vertical. They are apt not to 
be, as the patient generally throws her chest too far forward, thus 
slanting the thighs. If they are not vertical they are easily made 
so by asking the patient to move her chest back a little as the 
pillow is moved for her in the same direction. 
The knee-chest position is most useful for speculum examina- 



PJjr i JH 

B flt 



Fig. 14.— The Knee-Chest Position. Side View, Showing Vertical Thighs. 

tions of the vagina, bladder, and rectum, the abdominal pressure 
being removed, and the viscus in which the speculum is placed 
being ballooned by the atmospheric pressure admitted by opening 
the external orifice. 

To replace a retroverted or retroflexed incarcerated uterus, 
or an incarcerated tumor of the pelvis, often necessary to establish 
a diagnosis, the knee-chest position is invaluable. 

The lithotomy position is the dorsal position with the thighs 
flexed on the abdomen. The position is maintained by leg holders, 
of the Von Ott, Robb, or the Clover's crutch patterns, by different 
forms of slings holding the flexed thighs to the shoulders of the 



58 



PHYSICAL EXAMINATION 



patient with straps, or by leg holders attached to the operating 
table. The patient is placed in the lithotomy position just as 
in the dorsal position, with the addition that the thighs are kept 
flexed by some device. Without any apparatus whatever it is 
possible, and often convenient, especially in short operations, 
such as curetting, for one assistant to hold both legs with one 
hand and have the other hand free to assist the physician. To 
do this, the assistant, generally a nurse, places herself on the left 
side of the table (the patient's right side), facing the physician, who 




Fig. 15. — The Lithotomy Position. 

is seated in the chair at the foot of the table. She reaches across the 
patient's flexed limbs with her left arm, letting the right knee rest 
in her left axilla and grasping the left leg with her left hand. Thus 
her right hand is free to hold instruments for the doctor. 

The lithotomy position is used for examinations under ether, 
for operations, and for investigations where it is necessary to 
scrub up and asepticize the vulva and surrounding regions. 

The raised pelvis position, used only in cystoscopic examina- 
tions, is an exaggerated lithotomy position. It is best obtained 
on a table which has a mechanism for the Trendelenburg posture, 



PALPATION 



59 



but may be secured by placing a hassock or hard cushions covered 
with towels under the sacrum, so that the pelvis is elevated about 
ten inches above the level of the table, the legs being held by a 
Robb leg holder or by an assistant standing on a stool or box. 
This position tilts the pelvis backward and removes abdominal 
pressure from the bladder. 

The standing position is of occasional use in determining the 
degree of prolapse of the uterus and vaginal walls when full ab- 
dominal pressure is exerted, also the axis of the uterus under these 
conditions, and the holding power of a pessaiy. 





M.' 


1 




■^^^ ^\ 









Fig. 16. — The Raised Pelvis Position. 

The patient stands facing the physician with her right foot 
resting on a round of a chair eight or ten inches from the floor. 
The physician kneels on his left knee in front of her, or sits in a 
low chair resting his left elbow on his left knee. He anoints his 
left forefinger, and steadying himself with his right hand on her 
left hip, finds the vulva by sweeping the anointed middle finger 
of his left hand over the anal region, and then introduces the fore- 
finger, just as in the vaginal examination in the case of the dorsal 
position. Having the patient bear down or cough gives an idea 
as to the excursion of the uterus with forced expiration. 



60 



PHYSICAL EXAMINATION 



4. Odor as a Diagnostic Sign 

The sense of smell is sometimes an aid to diagnosis, as in detect- 
ing the characteristic odor of the vaginal discharge from uterine 
cancer, and the odor of urine or feces in the vaginal discharges in 
the case of urinary or fecal fistula?. Menstrual blood has a different 
odor from other blood. Certain vaginal discharges have a pecul- 




Fig. 17. — The Standing Position. 



iarly foul odor. The odor exhaled by a patient suffering with 
septicemia is characteristic, although, like other odors, not capable 
of definite description. Diabetic urine has a sweet smell and 
urine may be distinguished from other discharges by administering 
spirits of turpentine or asparagus to the patient by the month and 
noting the odor of violets or asparagin in the urine. 



COLLECTION OF DISCHARGES AND TISSUES 61 

Acetonemia, a form of intoxication with acetone occurring in 
diabetes, in infectious fevers, in intestinal fermentation, in gen- 
eral sepsis, and sometimes following gynecological operations, 
may be distinguished by the sweetish odor of the breath, 
described as like that of a pippin apple. 

5. The Collection of the Discharges and Tissues for 
Microscopic Examination 

Materials Needed. — 1. Half a dozen absolutely clean cover 
glasses. 2. A few culture tubes of hydrocele agar or blood serum 
(furnished by the pathologist). 3. Platinum wire loop. 4. Alcohol 
lamp. 5. Long-handled sharp knife. 6. Long-handled sharp- 
pointed scissors. 7. Uterine tenaculum. 8. Uterine dressing for- 
ceps. 9. Needle-holder, curved needle, and catgut. 10. Gauze 
packing. 11. Small bottle of ten-per-cent formalin. 

Bartholin's Glands. — If the discharge from the glands of Bar- 
tholin is to be collected for examination for gonococci or tubercle 
bacilli, the labia are separated and the vulva is wiped dry with 
sterile cotton pledgets. Grasp the gland to be investigated be- 
tween the thumb and forefinger, make gentle pressure, and transfer 
the discharge, which exudes from the mouth of the gland's duct, to 
a cover glass by means of a platinum wire loop or uterine applicator 
which has been passed previously through the flame of an alcohol 
lamp. Place a clean cover glass upon the first one, press the two 
gently together to spread the discharge evenly, slide the two apart, 
and allow to dry. The dry cover glasses may then be reapplied 
face to face and held together by an elastic band. They are then 
placed in an envelope which is labeled as follows: — 

Name of patient : 

Date: 

Source of material: 

Examine for (organism): 

Sent by Dr. 

The preparation properly labeled is then sent to the pathol- 
ogist for examination. 

Skene's Glands.— The orifice of the urethra and the introitus 
vagina? are wiped dry with sterile cotton pledgets. Introduce the 
finger into the vagina and make gentle pressure from above down- 



62 PHYSICAL EXAMINATION 

ward along the course of the urethra. As the ducts of Skene's 
glands open into the urethra just inside the urethral labia, any 
discharge from these ducts will contain a certain admixture of 
urethral discharge also. The urethra can hardly become infected 
without accompanying infection of Skene's glands, but this mixture 
with urethral discharge is unimportant from a clinical standpoint. 
If it is essential to examine the discharge from Skene's glands apart 
from that from the urethra, then the latter canal must be walled 
off with a small cotton pledget and pressure made only over Skene's 
gland. Transfer the discharge obtained to cover glasses as de- 
scribed under Bartholin's glands. 

The Cervical Canal. — The patient is placed in the Sims position 
by preference, although the procedure may be successfully carried 
out in the dorsal position. A speculum is introduced and the 
vagina cleansed with sterile cotton and water and then dried with 
dry cotton. A good exposure of the cervix can usually be obtained 
without the use of a tenaculum. The use of a tenaculum is often 
accompanied by bleeding which may contaminate the cervical 
discharge. Sometimes it is necessary to draw the cervix down 
with a tenaculum. In this case the instrument should be firmly 
fixed at the first attempt and held in place. A sterile tampon 
screw is most useful in obtaining cervical discharge. The instru- 
ment is introduced into the cervical canal not beyond the internal 
os and twisted until some of the discharge has been caught in the 
threads of the screw. Whether obtained with the screw or with 
the platinum wire loop the smear is made as described in the case 
of the glands of Bartholin and Skene. 

Cultures. — If cultures for the purpose of obtaining a bacterial 
growth from a discharge are to be made, the culture tubes are 
used. Collect a drop of the discharge on the sterile small wire 
loop which comes with the tube and smear it over the slanting 
surface of the material in the tube. Replace stopper, label care- 
fully, and return to the pathologist. It is possible to introduce 
the small wire loop into most cervical canals without dilatation, and 
it is much better to take the culture or smear without dilating 
the canal, because in the process of dilating the discharges are 
partly removed and mixed with blood and tissue. 

Removal of Tissue from the Cervix for Examination. — The Sims 
position usually offers the best exposure of the cervix for the 



COLLECTION OF DISCHARGES AND TISSUES 63 

removal of pieces of tissue for examination. In removing a 
suspicious piece of tissue for microscopic examination it is wise 
to cut out some of the apparently healthy tissue as well as the 
diseased portion, for it occasionally happens that the pathologist 
receives nothing but necrotic tissue and can form from it no diag- 
nosis whatever. A raw surface left by removal of tissue should be 
closed by suture or tamponed until all bleeding has been checked. 
Tissues removed by the curette, scissors, or knife for the purpose 
of diagnosis, are to be plunged intact and immediately into a ten- 
per-cent solution of formalin in water; then they are properly 
labeled, and sent to the pathologist. 



CHAPTER VI 
THE PHYSICAL EXAMINATION (Continued) 

III. The examination (continued) : 6. Inspection of the abdomen, p. 64. 
Method of performing it, p. 65. Appearances to be noted, p. 65. En- 
teroptosis, p. 67. 

7. Palpation of the abdomen, p. 68. Method of performing it, p. 69. 
Points to be determined by palpation, p. 69. Palpation of the kidneys, p. 
70. 

8. Percussion of the abdomen, p. 71 ; Auscultation of the abdomen, p. 
72 ; Mensuration of the abdomen, p. 74 ; Gauze records of abdominal 
tumors, p. 74; The X-rays in diagnosis, p. 76. 

III. THE EXAMINATION (Continued) 

6. Inspection of the Abdomen 

Attention will be directed to the abdomen to a greater or a 
less degree according to the nature of the disease present in any 
given instance. In the case of late pregnancy, and of tumors of 
abdominal evolution, whether originating in the pelvis or not, 
investigation of the abdomen is of chief importance. 

In suspected uterine disease the vaginal and bimanual examina- 
tions usually precede the examination of the abdomen. In the 
case of a large abdominal swelling the abdomen is first inspected. 

For the examination of the abdomen it is not so necessary that 
the patient should lie on a hard surface as in the case of the vaginal 
examination. However, the table is most convenient for the 
physician because he can stand up and make his inspection, palpa- 
tion, percussion, and mensuration when in a position comfortable 
to himself; not, as in the case where the patient is on a low bed or 
couch, with bent back and strained muscles, conditions which are 
not conducive to most careful investigation. The patient on a 
table is comfortable enough for the brief time required for the 
examination. 

All the patient's clothing has been loosened and the corsets 

64 



INSPECTION OF THE ABDOMEN 



65 



removed, as previously described. The sheet covers the legs, 
thighs, and pubic region. The raised skirts cover the chest, or, 
if the skirts have been removed, another sheet is used for this pur- 
pose. 

To investigate the abdomen to the best advantage the patient's 
head should be raised a little on a pillow and the thighs should be 
slightly flexed. Too much flexing of the thighs or raising the head 
and thorax high will decrease the portion of the abdomen available 
for examination. 

For purposes of description the abdomen may be divided 




Margin of ribs B 



Crest of ilium 



Fig. 



Spine of pubes 

18. — The Abdomen Divided into Quadrants 
and the Bony Landmarks Indicated. 



arbitrarily into four regions, by two lines, one a vertical line pass- 
ing through the ensiform cartilage, the umbilicus, and the symphysis 
pubis, and the other passing through the umbilicus at right angles 
to the vertical line. The four regions so made may be called the 
right upper quadrant, the right lower quadrant, the left upper 
quadrant, and the left lower quadrant. 

On observing the abdomen one notices symmetry or asymmetry, 
distention or retraction, increased or diminished motion of the 
abdominal walls on respiration, and the appearance of the skin. 
5 



66 PHYSICAL EXAMINATION 

To detect symmetry, stand at the foot of the examining table and 
look at the abdomen from below. Tumors of the ovary as well as 
tumors of the kidney are apt to cause asymmetrical enlargement 
of the abdomen; whereas, tumors of the uterus and ascites more 
commonly produce symmetrical enlargement. One notes bulging 
in the flanks and a flattening of the anterior aspect of the abdomen 
due to ascites, or to lax abdominal walls, with or without an abnor- 
mal amount of fat in the panniculus adiposus. 

A tumor rising from the pelvis, unless of great size, is usually 
outlined by the abdominal walls. In ovarian cysts the abdomen 
is irregularly ovoid in shape with its point of greatest protuberance 
below the umbilicus, and there is no bulging in the flanks. In 
the case of multilocular cysts the loculi may be distinguished by 
sight in exceptional cases through a thin abdominal wall, so nodules 
of a malignant growth in an ovarian cyst can sometimes be dis- 
tinguished by the eye. Large multiple fibroids also show occasion- 
ally through the skin as lumps of irregular shape; an interstitial 
fibroid forms a protuberance of a smoother outline that is generally 
situated in the median line. 

Observe the movements of the abdominal walls. The normal 
movements on inspiration and expiration extend over the entire 
surface from ensiform to pubes. In cases of large tumors springing 
from the pelvic cavity the movement is confined to the epigastric 
region if the distention is great, also if there are adhesions between 
the tumor and the parietes there may be motion only in this region. 
Sometimes, when there are no adhesions present, the abdominal 
wall can be seen to glide up and down over the surface of a tumor 
of moderate size. 

Waves of peristalsis in the intestines may be noted in a patient 
with thin flaccid walls and retracted abdomen, also pulsations of 
the abdominal aorta. In pregnancy the situation of greatest in- 
tensity of fetal movements may be observed. 

Separation of the recti, due to distention of the abdomen during 
previous pregnancies, often leaves a ventral hernia through which 
a tumor, the pregnant uterus, or the abdominal contents ma}' 
protrude. Palpation of the abdominal and pelvic organs is ren- 
dered most easy in these cases. v 

The appearance of the skin of the abdomen is of interest as 
showing discolorations from blisters and counterirritants, indica- 



INSPECTION OF THE ABDOMEN 



67 



tions of previous treatment, also the presence of edema or skin 
diseases. Enlargement of the superficial veins indicates pressure 
on the deeper vessels. Excessive distention of the abdomen 
renders the skin white and glossy in appearance, whereas, when the 
walls are lax, the skin has a shriveled or puckered look. 

The lineae albicantes, red and purple when recent, and white 
and glistening when old, are to be looked for especially over the 
flanks. They indicate previous stretching of the skin, but are not 
pathognomonic of pregnancy, as they occur in 
virgins who have grown rapidly and then lost 
subcutaneous fat. 

Pigmentation of the linea alba (linea nigra) and 
increase of pigment about the umbilicus and lower 
abdomen occur in some women during a first preg- 
nancy. This pigmentation persists, but is of no 
diagnostic importance in a subsequent pregnancy. 

When the patient is sick in bed with peritonitis, 
the characteristic way in which she holds herself, 
with knees drawn up to relieve all strain on the 
abdominal parietes, is to be noted. 

Enteroptosis. — In some cases it is advantageous 
to put the patient in the standing position for the 
purpose of inspecting the abdomen; especially is 
this desirable in suspected ptosis of the abdomi- 
nal viscera, a condition often associated with 
uterine disease. 

Here we must inspect not the abdomen alone, 
but the entire trunk. The patient stands, first, facing the phy- 
sician, entirely nude except for a sheet held by a nurse draping 
the lower limbs and pubic region. Then she stands so that he 
sees her in profile. In typical enteroptosis one notes a long, nar- 
row thorax, with flat and sunken epigastric region. The waist is 
long, the abdomen is prominent, the shoulders are rounded, and 
when seen in profile the lower back is nearly flat instead of pre- 
senting, as normally, a forward curve, with shoulders and hips well 
back and spine bent forward in the lumbar region. There is gen- 
erally an absence of adipose tissue in these patients and the muscles 
are apt to be slender and flabby. 




Fig. 19.— The 
Body Pose in 
Enteroptosis. 



68 PHYSICAL EXAMINATION 



7. Palpation of the Abdomen 

To palpate the abdomen successfully, the patient should be pre- 
pared as for inspection, that is, in the dorsal position with the head 
slightly raised on a pillow, all clothing loosened, the feet supported, 
and the pubic region, thighs, and legs covered by a sheet. The 
physician, standing on the patient's right, places both hands, 
warmed, and with finger nails cut short, on the abdomen. No 
abrupt or rapid movements should be made, and, for the purpose of 
distracting the patient's attention and thus favoring relaxation, 
it is advisable at this juncture to ask some question as to the health, 
not directly referable to the abdomen. 

By care and patience the tendency of the abdominal muscles 
to contract when stimulated by manipulation may be overcome. 
Oftentimes more than one sitting is necessary to accomplish this 
result, and in this event the diagnosis must be held in abeyance 
until after a second examination. It is better to make two or more 
attempts, except in urgent cases, rather than resort to an examina- 
tion under an anesthetic, because with increasing experience the 
physician learns an added amount from each palpation, and hav- 
ing gained the patient's confidence and treating every case accord- 
ing to her individuality, he is able more frequently to dispense with 
an anesthetic. 

The utmost gentleness should obtain always. The harder the 
pressure, the greater the resistance of the abdominal walls and 
the greater the blunting of the physician's tactile sense. Further- 
more, it has happened several times in the experience of the writer, 
that a student novice has ruptured a thin-walled or necrotic ovarian 
cyst or a circumscribed collection of peritonitic fluid, by too vig- 
orous palpation. 

A thin, relaxed abdominal Wall permits of palpation of the 
promontory of the sacrum, and the pulsations of the abdominal 
aorta are to be felt distinctly. The anterior superior spines and 
the crests of the ilia, the symphysis pubis and the borders of the 
ribs, body landmarks, are always to be made out. Thick and 
tense abdominal walls interfere with palpation. 

It is well to have a definite system to follow in palpating the 



PALPATION OF THE ABDOMEN 69 

abdomen. Begin with the lower quadrants and proceed to the 
upper quadrants. (See Figure 18, page 65.) By making firm 
but gentle, deep pressure, the patient at the same time taking a 
deep breath, the hands, flat on the abdomen, are brought together 
and a fold is grasped between them so that an estimate is formed 
of the thickness of the abdominal walls and their degree of tension. 
Avoid as far as possible digging into the flesh with the tips of the 
fingers, using instead the palmar surfaces of the last phalanges, 
the location of the trained tactile sense. 

We may learn by palpation, of the presence of a tumor, also its 
situation, size, shape, mobility, consistency, and point of attach- 
ment. We determine a point of tenderness on pressure, indicating 
localized peritonitis. In a majority of cases we may palpate the 
normal kidneys, more easily if they are enlarged or displaced. We 
palpate the edge of the normal or enlarged liver, and a displaced 
liver, as in enteroptosis, also a distended gall bladder, or an en- 
larged spleen. A loop of bowel distended with feces and also the 
distended urinary bladder may be made out by palpation. 

Suppose a tumor is present; first we determine its situation 
by making gentle, firm pressure with both hands, noting in which 
quadrant or quadrants of the abdomen it is situated. The ab- 
dominal walls should move with the hands over the underlying 
organs or the tumor. Tumors situated in the structures of the 
abdominal wall move with the wall on inspiration and expiration 
over the organs underneath. Tumors of the abdominal and pelvic 
organs that are adherent to the abdominal parietes limit the 
motion of the walls on respiration. Exceptionally, in cases where 
the walls are lax and the tumor is not excessively large, the physician 
is able to pick up the abdominal wall and determine if it is adherent 
to the tumor beneath. All the abdominal organs normally move 
more or less during respiration, — those organs nearer the diaphragm, 
as the liver and kidneys, moving the most, while those in the 
bottom of the abdomen are less affected. The size of the tumors 
can be learned only approximately. It is to be borne in mind that 
some tumors vary in size at different times: for instance, an 
ovarian cyst is smaller after there has been free catharsis from the 
bowels, and a fibroid tumor of the uterus is larger just before the 
catamenia and smaller just after. 

The shape of the tumor is made out by palpating it in several 



70 PHYSICAL EXAMINATION 

directions. To this end the examiner shifts his position to the 
left side or to the foot of the examining table. 

The mobility of the tumor is ascertained by grasping it between 
the two hands and moving it about. Changing the patient's 
position to the lateral position may cause the tumor to fall by 
gravity to the dependent side. Ovarian tumors tend to gravitate 
into the abdominal cavity if the patient is put in the knee-chest 
position. The excursions of a movable tumor show us something 
as regards adhesions and the point of attachment and length of 
the pedicle. Traction on the pedicle generally causes pain re- 
ferred to the situation of the pedicle. 

The consistency of a tumor is often a difficult matter to pass on. 
Waves of fluctuation are made out by a combination of palpation 
and percussion. The hand of an assistant is placed, ulnar edge 
down, in the longitudinal axis of the abdomen and firm pressure is 
made. This is to eliminate the wave which may be transmitted by 
the fat of the abdominal wall. The physician taps one side of the 
abdomen and notes with the other hand, placed on the opposite 
side, oscillations which may be transmitted through the fluid. 
If a cyst is filled so that the fluid is under great pressure and if 
the cyst walls are thick, the fluid waves may be indistinguishable. 
So also, if the fluid is of a thick consistency, fluctuation may be 
absent. 

Peristaltic contractions of a piece of intestine are sometimes 
to be distinguished and also the rhythmical contractions of a 
pregnant uterus. To determine either of these it is necessary to 
let the hand rest gently on the abdomen for a considerable length of 
time. 

The point of attachment of a tumor may be learned by moving 
the tumor while the hand is held on a neighboring organ and noting 
whether the organ moves too, or by moving the organ and noting 
the behavior of the tumor. 

Palpation of the Kidneys. — Palpation of the kidneys is best done 
with the patient in the dorsal position. The physician stands at 
the patient's side facing toward her head, his left hand is placed 
under the flank and his right hand over the flank, while the patient 
takes a deep breath. This process is repeated, the hands coming 
together a little more with each expiration. Time, gentleness, and 
gradual movements are important factors in this manipulation. 



PERCUSSION OF THE ABDOMEN 71 

The right kidney, being a little lower than the left, is more accessible 
to palpation. With practice it will be found that there are com- 
paratively few cases, — and these patients having very stout and 
rigid-walled abdomens, — in which the lower poles, at least, of the 
kidneys can not be felt. 

In the case of movable kidney, generally the entire kidney can 
be outlined, especially where it is enlarged. Pressure on a tuber- 
culous or hydronephrotic kidney will frequently force turbid 
urine through the ureter into the bladder. If the bladder has 
been emptied by catheter previous to the examination and clear 
urine obtained, such a procedure assists materially in establishing 
the diagnosis, for a second catheterization following palpation 
draws off cloudy urine. 

To determine the extent of the downward excursion of a mis- 
placed kidney the flank is palpated either in the sitting or in the 
standing position. In the sitting position the patient sits on the 
foot of the table with her feet in a chair, and bends forward slightly. 
In the standing position she stands facing the table and about a 
foot from it. Placing both hands on the table she leans forward 
so that part of her weight is taken on the hands; thus the abdom- 
inal muscles are relaxed. This manipulation can be executed 
best with the assistance of a nurse or another woman, because the 
patient can not hold up her loosened clothing and bear part of the 
weight on her hands at the same time. Personally, I have learned 
to place the chief reliance on the dorsal position for palpation of 
the kidneys, except to make out the amount of extreme downward 
excursion, when sometimes the standing, and at others the sitting, 
position gives the better result. 

8. Percussion, Auscultation, and Mensuration of the 

Abdomen 

The combination of palpation and percussion for the detection 
of fluid waves in the abdomen has been described in the discussion 
of palpation. 

Percussion is best practiced with the patient in the dorsal position. 
By it we determine the situation of the lower margin of the liver- 
dullness, the area of stomach and colon tympany, splenic dullness, 
the dullness due to fecal accumulations in the bowels or urine in 



72 PHYSICAL EXAMINATION 

the bladder, and the dullness caused by free fluid in the peritoneal 
cavity or by the fluid or solid constituents of a tumor. 

Unfortunately we have no standard of comparison in percussion. 
We can not compare the percussion note of one side of the abdomen 
with that of the other, and the conditions are constantly varying, 
due to changeable quantities of fluid, solid and gaseous matters 
in the stomach and bowels, and the encroachment of one organ on 
another. Also, there are to be considered the variations caused 
by the normal mobility of the abdominal organs. 

Nevertheless, percussion is a valuable adjunct to palpation. 
Its chief use in gynecological diagnosis is in differentiating between 
ascites and a cystic ovarian tumor. In the case of ascites, the flanks, 
being the dependent portion of the abdominal cavity and there- 
fore occupied by fluid, are dull to percussion. The intestines, 
filled more or less by gas, float on top of the fluid, and give an area 
of resonance in the umbilical region. Shifting the position of the 
patient to one side sends the fluid (unless by chance it is walled 
off by adhesions) to the dependent side, and the resonance is to be 
found on the upper side and flatness below. In rare cases, when 
the ascitic fluid greatly distends the abdomen, there may be no 
change in the area of dullness on shifting the position of the patient. 

In the case of a large ovarian cyst, the resonance is in the epi- 
gastric region, the intestines having been forced there b}^ the tumor 
and the dullness is over the area occupied by the tumor. Change 
of posture does not alter the areas of dullness and resonance. (See 
Figures 132 and 133.) If the gut has a short mesentery, the 
intestinal resonance may be in the upper parts of the flanks, or, 
in case the intestine is occupied by fluid or solid fecal matter, there 
may be little or no resonance, the entire abdomen being dull Or 
flat to percussion. A large deposit of fat in the omentum may 
cause dullness in any situation. 

In gastroptosis one detects the displaced stomach by inflating it 
with gas by giving the patient a dram of bicarbonate of soda in 
half a glass of water, followed by half a dram of tartaric acid in 
another half-glass of water. Percussion is performed with the 
patient in the dorsal position and also in the standing position. 
The lower margin of the liver is percussed in these two positions 
and the differences of level noted. 

Auscultation is of value chiefly in diagnosing pregnancy. The 



AUSCULTATION OF THE ABDOMEN 73 

detection of the fetal heart-sounds, with a rate entire y different 
from that of the maternal pulse, is one of the absolutely distinctive 
signs of pregnancy. They are seldom discernible before the twen- 
tieth week, although certain observers report having heard them 
as early as the twelfth week. After the twenty-eighth week they 
should almost always be heard, if the child is alive, at any rate 
after repeated examinations. Hydramnios or thick abdominal 
walls may prevent the sounds from being transmitted to the ear. 
The sounds are usually heard over the child's back. Therefore, 
since left positions of the occiput are the most common, the heart- 
sounds are generally to be heard on a line drawn from the um- 
bilicus to the left anterior superior spine of the ilium. 

If they are not heard in this region the entire abdomen should 
be auscultated carefully. Changes in the position of the child may 
make the sounds audible at one time and inaudible at another, so 
that, should there be a failure to hear them, more than one exam- 
ination is to be made. Occasionally the child's position may be 
changed by manipulation for purposes of auscultation, so that its 
back comes against the abdominal parietes of the mother. Some 
plrysicians prefer direct auscultation, with the ear applied to the 
abdomen, to the mediate auscultation of the stethoscope. 

The binaural stethoscope is the best means for detecting the 
fetal heart-sounds. Its mouth should be moistened to do away 
with the noise generated by the slipping of the stethoscope on the 
skin. Generally the lightest possible pressure of the stethoscope 
on the skin is advisable, and to this end it is best to let it rest by 
its own weight and not to hold it with the fingers. The beating of 
the fetal heart (130 to 140 beats a minute) has been likened to the 
ticking of a watch under a pillow. To make the diagnosis sure, 
the rate should be counted for a minute, and thus it is differentiated 
from the maternal pulse, which is counted by the physician's 
finger on the mother's radial artery. 

The uterine souffle, or bruit so called, is an intermittent blowing- 
sound synchronous with the patient's pulse. It occurs not only 
in pregnancy but also in fibroids of the uterus and in other uterine 
and even ovarian tumors, and is probably due to increased circula- 
tion in enlarged blood-vessels. It is of no special diagnostic im- 
portance. The noises made by gas in the stomach and intestines 
are to be detected by auscultation. 



74 PHYSICAL EXAMINATION 

In cases of peritonitis, one may determine by this means whether 
the peristaltic movements of the intestines are still present. Fric- 
tion sounds made by the rubbing together of roughened surfaces 
of tumors and adjacent structures may sometimes be heard, also 
the murmur transmitted from an abdominal aneurysm. 

Mensuration is a means of determining the rate of growth of 
an abdominal tumor. Exact measurements are impracticable 
because of the varying state of the bowels as to distention or 
relaxation, and also because of the yielding nature of the tissues 
and the mobility of the tumors. Nevertheless, much may be 
learned, in cases of chronic enlargement of the abdomen, by making 
careful measurements at repeated examinations several weeks or 
months apart. These are made partly with a tape measure and 
partly with a pelvimeter, and, for purposes of comparison, all 
subsequent measurements should be made under as nearly similar 
conditions as to time of day, time after menstruation, state of the 
bowels, etc., as possible. They should always be made with the 
patient in the same position and with all clothing loosened. Very 
light contact pressure with the tape or pelvimeter on the skin is best. 

The measurements to be taken are: — the greatest circumference; 
the circumference at the umbilicus ; the distance from the cnsif orm 
cartilage to the symphysis pubis; from the umbilicus to the an- 
terior superior spine of the ilium on each side; and the greatest 
diameter of the abdomen as measured with the pelvimeter, the 
patient standing, one point of the pelvimeter being placed over 
the most prominent portion of the abdomen, and the other over 
the spinous process of some definite counted sacral vertebra. 

Dr. Howard A. Kelly (" Medical Gynecology," p. 17) has devised 
a method for making permanent gauze records of abdominal 
tumors and displaced viscera. The patient being in the dorsal 
position, the physician outlines the tumor and the landmarks, 
such as anterior superior spines of the ilia, margins of the ribs, 
symphysis, and umbilicus, on the skin of the abdomen with an 
aniline pencil. If the skin does not take the pencil marks well, 
wet it with a little alcohol. Lay a plate of glass over the abdomen 
and on it place a piece of stiffened gauze (suisse, nainsook, or organ- 
die). The skin markings are visible through the glass. Reproduce 
them with a crayon pencil on the gauze. File away the gauze, 
labeled with the patient's name and the date, for future reference. 




Fig. 20. — A Permanent Gauze 



Record of an Abdominal Tumor. (Kelly.) 



75 



76 PHYSICAL EXAMINATION 

The X-rays in Diagnosis. — The X-rays are of supplementary 
diagnostic value in detecting stone in the ureter or kidney, and in 
determining ptosis of the stomach and intestines when these organs 
are filled with bismuth in suspension, also the presence of bone in 
tumors, — conditions important for the gynecologist to recognize. 
One skilled in the use of the Roentgen rays should be called in, as 
the neophyte is apt to be misled by the appearances seen in the 
photographic plates, and to put a wrong interpretation on their 
showings. 



CHAPTER VII 

THE PHYSICAL EXAMINATION (Concluded) 

III. The examination {concluded) : 9. Instruments and their use in 
diagnosis, p. 77: General remarks, p. 77. The uterine sound, p. 78: When 
to pass it, p. 78; Methods of passing, p. 79; Facts to be determined by the 
use of the sound, p. 80; Cautions, p. 82. The uterine probe, p. 82. The 
uterine dressing forceps, p. 83. The uterine tenaculum, p. 84. The 
vulsellum, or double tenaculum forceps, p. 84. The vaginal speculum, p. 
85: The bivalve, or duckbill speculum, p. 85; The Neugebauer bivalve 
speculum, the Ferguson speculum, the Simon speculum, and the Edebohls 
speculum, p. 86; The Sims speculum, p. 87. The Hunter depressor, p. 
88. The Emmet curette forceps, p. 89. The uterine curette, p. 90. 
Curetting, p. 90: Dangers of curetting, p. 93. Digital exploration of the 
uterine cavity, p. 94. Pelvimetry, p. 95: External or Baudelocque's 
conjugate diameter, p. 96; The oblique conjugate diameter, p. 97; The 
transverse diameter, p. 98; The transverse diameter of the outlet, p. 98. 
The capacity of the pelvic cavity, p. 98; The oblique diagonal diameters, 
p. 98. 

THE EXAMINATION (Concluded) 
9. Instruments and their Use in Diagnosis 

In a majority of gynecological diseases the diagnosis is made 
without the use of instruments. They are not the most important 
part of the physician's equipment. No matter how ingeniously 
constructed, and be they ever so well adapted to their uses, instru- 
ments in these days can not take the place of the educated touch. 
The physician, particularly the American physician, with his native 
mechanical bent, although mindful of the revolutionizing of 
gynecology by the speculum (which his countryman, J. Marion 
Sims, gave to the world), should forswear the wiles of the instru- 
ment-maker and devote his attention to training his touch, leaving 
instruments to the last. 

The immediate followers of Sims and Emmet wen 1 so pleased 
with the newly discovered vaginal speculum and with their ability 
to inspect the vagina by its skillful use, that they were quite content 

77 



78 PHYSICAL EXAMINATION 

to rest their diagnoses of uterine disease on what they saw through 
the speculum. Hence it followed that for the time other means of 
investigation were slighted and only in recent years has the pro- 
fession escaped from the thrall of the speculum. 

Out of a number of instruments each examiner and operator 
will have his personal preference for those which seem best to 
serve his needs. My full kit of instruments is to be found in 
Chapter IV., page 28. 

The Uterine Sound. — The uterine sound, although employed less 
and less as skill in the bimanual touch increases, is on the whole 
the most valuable of the instruments used in diag- 
^ nosis. In the days of Peaslee, Simpson, and Sims, 
f the use of the sound was much abused, as the other 

means of diagnosis had not been perfected at that 
time. The student was taught to pass the sound in 
nearly all cases of uterine disease, and, as aseptic 
methods were unknown, the results to the patient 
were too often disastrous. Not only was the sound 
passed into the uterine cavity, but malpositions of 
the uterus were forcibly corrected by this means, thus 
adding trauma to infection. At the present time the 
sound is employed to confirm a diagnosis made by the 
bimanual touch, and in certain rare conditions to make 
a diagnosis where the touch can not be used. 

The sound is to be preferred to the probe because 
the slightly larger end of the sound will slip over 
The Uterine irregularities in the mucous membrane lining the cavi- 
Sound. ties of the cervix and the body of the uterus, while 

the tip of a probe will catch in them. A sound of 
small caliber made of flexible copper, with a knob at the distal end, 
one side of the handle being rough and the other smooth, should be 
chosen. One side of the handle is made rough so that the operator 
may be informed as to the direction taken by the point of the bent 
instrument when sounding a deep and tortuous uterine cavity or 
sinus. The sound may be graduated in inches or centimeters, 
according to the preference of the physician. It is easier to keep 
it clean if it has no notches. The measurements are taken by mark- 
ing the depth to which it has entered the uterus, by means of the 
finger tip held against the sound, or the dressing forceps grasping 



INSTRUMENTS AND THEIR USE 79 

the sound at the external os and then, on withdrawing it, compar- 
ing the measurements with a measured scale on the table on which 
the instruments are placed. 

Before passing the sound the vagina must be cleansed in every 
case. We do not know what bacterial growth may be present in 
the vagina. Assuming that there are no pathogenic organisms 
present under normal conditions, some are introduced from the 
external genitals in the course of the vaginal touch, which always 
precedes the use of the sound. To cleanse the vagina, swab it out 
several times with pledgets of absorbent cotton held in the uterine 
dressing forceps and dipped in a warm solution of creolin and 
water (one per cent). 

The sound may be passed (1) bimanually, the patient being in 
the dorsal position. To do this the physician seizes a piece of 
absorbent cotton in the uterine dressing forceps held in his right 
hand, and carries it through the warm creolin solution; now de- 
pressing the patient's perineum with his left forefinger in the 
vagina, he swabs out the entire vagina, repeating the process 
several times. Laying down the dressing forceps he takes up the 
sound. The situation of the external os is determined with the 
tip of the left forefinger, and the knob-like end of the sound is 
carried along the left forefinger until it enters the os. The further 
manipulations are directed by the information as to location, axis 
and shape of the uterus, gained by the bimanual touch. It is 
customary to bend slightly the distal two inches of the sound 
toward the roughened side of its handle. The sound is held lightly 
in the right hand and allowed to slide in by its own weight. For- 
cible movements are absolutely contrainclicated and unnecessary. 
The physician who uses force thereby demonstrates that he has 
failed in his bimanual touch. If the sound does not pass readily 
it should be withdrawn and the end bent at a different angle and 
reintroduced. Remember that the barriers to the introduction 
of the sound are at the external and internal ora. The internal os 
is always closed except when blood is passing out of the uterine 
cavity, after labor, or in certain pathological states. 

In some cases where the uterus is sharply flexed, and when it is 
high in the pelvis, the cervix may be grasped with a tenaculum 
and drawn toward the vulva to facilitate the introduction of the 
sound. The tenaculum should be a single one, introduced into the 



80 PHYSICAL EXAMINATION 

cervical canal, not a double tenaculum, which makes two holes in 
the cervix and may start a hemorrhage and cause pain. 

The sound may be passed (2) by sight. For this purpose the 
patient is in the dorsal, the Sims, or the knee-chest position. If 
in the dorsal position the bivalve speculum is introduced and the 
vagina cleansed. The cervix is steadied with the tenaculum and 
the sound inserted in the uterine cavity. If in the Sims position 
the Sims speculum is introduced, and the manipulations are as 
in the dorsal position. If in the knee-chest position, the Sims 
speculum is introduced and the vagina balloons with air, the uterus 
falling forward toward the abdomen. In this position' it will be 
found necessary generally to seize the cervix with a tenaculum and 
raise it before the sound will enter. 

The uterine sound shows the depth and direction of the uterine 
canal, the size of the external and internal ora, the shape of the 
uterine cavity, situation of lacerations of the cervix, irregularities 
of the mucosa, the situation of the pedicle of a uterine polyp or 
submucous fibroid, the tonicity of the uterine walls, and, by biman- 
ual touch with the sound in the uterus and the hand on the 
abdomen, the thickness of the uterine walls. 

In passing the sound one measures the distance from the ex- 
ternal os to the internal os where the tip of the sound catches, and 
thus estimates the length of the cervical canal. The remaining 
distance from the internal os to the fundus gives the depth of the 
uterine cavity proper. In this way are distinguished the uterus 
of the little girl, the so-called infantile uterus with its long cervix 
and short body, and hypertrophic elongation of the cervix, an 
exaggeration of the infantile uterus; the atrophic uterus of old age 
with small body and shortened cervix; lactation atrophy, and the 
uterus deprived of its cervix by amputation. 

The uterine cavity, as a whole, is increased in size in pregnancy, 
subinvolution, hypertrophic elongation of the cervix, and new 
growths. It is diminished in atrophic conditions, — either failure 
of development or acquired atrophy,— in inversion, and in new for- 
mations encroaching on the cavity. 

In investigating the direction of the uterine canal it must be 
borne in mind that the cervical canal may extend in one direction 
while the uterine cavity is at an angle to it, as in anteflexion and 
retroflexion. Inflammatory exudate or new growths in the neigh- 



INSTRUMENTS AND THEIR USE 81 

borhood of the uterus, by causing displacement, may alter the 
direction of the canal. 

Stenosis of the external os is common in certain forms of ante- 
flexion where we find the so-called " pinhole os," in senile atrophy, 
and following improperly performed operations on the cervix. 
False stenosis of the internal os is apparent in many cases of 
anteflexion, the sound passing when the uterus has been straight- 
ened by traction on the cervix with a tenaculum. True stenosis 
is found after injuries of the internal os due to too vigorous curetting 
or to steaming; from inflammation in the tissues in this neighbor- 
hood, as in cases of cancer of the cervical canal (adenocarcinoma) ; 
in senile atrophy; and it may be congenital, as in hematometra. 

Both the internal os and the external os may be enlarged in 
subinvolution and as a result of laceration. 

It is important to determine whether the internal os also is 
lacerated in cases where there are lacerations in the external os. 
This is done by the sense of touch communicated through the 
sound. The situation and extent of laceration are determined 
partly by recognizing the landmarks in the mucosa of the cervical 
canal in the form of the arbor vita? and by trying to reconstruct 
the cervix in its original form by rolling the everted edges together 
with tenacula, also by placing the sound over the arbor vitse with 
its tip at the middle of the fundus and noting whether a laceration 
is on one or both sides of the sound. (See Chapter XIII., p. 209.) 
The sound gives a good idea of the shape and size both of the 
cervical canal and of the uterine cavity proper. 

The physician while passing the sound should keep in mind 
always the shape of the normal uterine cavity (see Figures 64, 67, 
and 68, pp. 166, 171, 172), an isosceles triangle, having as bound- 
aries front wall, back wall, fundus, and internal os. There are 
no side walls, but in their place are the two furrows formed by the 
meeting of the front and back walls, beginning below at the internal 
os and ending above in the orifices of the Fallopian tubes. 

The internal os being relaxed or dilated, the properly bent sound 
is passed lightly and methodically over anterior wall, posterior 
wall, fundus, and lateral furrows, detecting fungositics or inequal- 
ities in the mucosa, or a pedunculated growth. The last is very 
difficult to do, and is not possible in all cases. It is surprising, 
however, how much may be learned by training the sound-touch. 
6 



82 PHYSICAL EXAMINATION 

By sound-touch the firm, elastic resistance of the healthy uterus 
may be differentiated from the sclerosed tissues of subinvolution 
or the soft tissues of the septic uterus. 

With the sound in the uterus and the fingers on the abdomen or 
with a finger in the rectum, it is possible sometimes to estimate the 
thickness of the uterine walls. 

Cautions. — The greatest caution is to be exercised in passing 
the soimd in infectious cases ; especially in gonorrhea, because the 
sound will carry the infective bacteria beyond the 
natural barriers at the external and internal ora. Also 
in cases of septicemia and advanced cancer, the sound 
should be used with circumspection because of the 
danger of perforation which is most easily made under 
these conditions, the uterine structure often being so 
soft as to offer practically no resistance to the pass- 
age of the soimd through it. Perforation occurs oc- 
casionally under such conditions in the hands of the 
most careful. Never pass the sound into the uterine 
cavity without first asking the patient the date of her 
last menstruation. Make this an invariable rule, and, 
not forgetting the possibility of prevarication, and 
also having fresh in mind the result of the bimanual 
examination, — the invariable precursor of the use of 
any instrument, — you will avoid making that most 
serious of all gynecological mistakes, the sounding of 
the pregnant uterus. 
Fig. 22.— The misplaced uterus should never be replaced 
e enne ^^ ^ e SO und, a practice much in vogue twenty 
years ago. If the uterus is freely movable, not held 
by adhesions, it can always be replaced by bimanual manipulation 
together with traction by a tenaculum in the cervix, making use 
of one or more of the various gynecological positions. One at- 
tempt should not discourage. More favorable conditions may 
obtain at another time. 

Besides its use in the uterus the sound may be used to investigate 
the bladder — its situation, as in prolapse of the uterus and in 
tumors; also the situation of sensitive areas and the presence of 
stone or phosphatic deposits in the bladder. 

The Uterine Probe. — The uterine probe has the same uses as the 



INSTRUMENTS AND THEIR USE 



83 



surgical probe, and besides having a handle and a long shaft, it 
can be used to investigate the interior of small uterine canals, and 
may be bent to conform to tortuous uterine 
interiors or long sinuses. The probe supple- 
ments the sound, but as an aid to diagnosis 
should not supplant it. 

The Uterine Dressing Forceps. — My pref- 
erence for a dressing forceps is one made 
on the scissors principle, as this seems best 
to supplement the hand in uterine manipula- 
tions. The forceps known as Bozeman's, — 
detachable blades with double curve, catch, 
and serrated jaws, — makes one of the most 
useful instruments known to 
gynecological art. With it we 
not only grasp pledgets of cot- 
ton with which to wipe awa}^ 
the discharges and cleanse the 
vagina, but also remove a bit 
of stringy, tenacious discharge 
from the os uteri, or pieces of 
tissue from the os or vagina for 
microscopic or bacteriological 
examination. 

By grasping with the for- 
ceps the uterine sound while 
in the uterus at a point 
where it projects from the 

external os, the depth of the uterine cavity is 
measured on a clean towel when the sound is with- 
drawn. 

The curves in the blades of the instrument permit 

of its entering the uterine cavity or a sinus while the 

hand which holds it does not obstruct the operator's 

view. Being made on the scissors principle, levers 

of the first class with the fulcrum some distance 

from the jaws, one is able often to open the jaws in a cavity 

(uterine cavity or sinus), after passing through a narrow opening 

(internal os), or skin entrance, — something that a forceps made 




Fig. 23.— Uterine 
Dressing Forceps. 



Fig. 24.- 
Uterine Ten 
aculum. 



84 



PHYSICAL EXAMINATION 



on the principle of the Sims uterine dressing forceps, levers of the 
third class, will not do. 

In an emergency the Bozeman dressing forceps may be used as 
a hemostatic forceps. The jaws may be wound with absorbent 
cotton and thus used to make applications to the interior of the 
uterus or a sinus, and the forceps may be used also to hold nitrate- 
of-silver pencils for cauterizing granulations. 

The Uterine Tenaculum. — This is to-day a neglected instrument. 
When used in days gone by to manipulate silver wire, the tenac- 
ulum was indispensable. The form of tenac- 
ulum devised by Emmet and Sims for shoul- 
dering silver wire is the best for general use — 
i.e., one with a right-angled end, instead of a 
hook, for the reason that it holds the tissues at 
the point where it is introduced, — is less likely 
to tear not only the tissues of the patient but 
the operator's finger, and it is more readily 
withdrawn from the tissues when desired. It 
should be introduced into diseased tissue when 
possible and does less damage and stays in 
place better in the hard resistant mucosa of the 
cervical canal than in the friable mucous mem- 
brane covering the vaginal portion of the cer- 
vix. 

Although the double tenaculum forceps, or 
vulsellum, holds more firmly than the single 
tenaculum, the single one makes but one punc- 
ture, causes less pain and no hemorrhage, and 
is to be preferred in the routine of examina- 
tions. 

Tenacula are of immense benefit in diag- 
nosis, in steadying and drawing down the cer- 
vix both for the bimanual examination and 
for inspection, in rolling together the lips of a torn cervix to estimate 
the situation and extent of the tears, to reconstruct the lacerated 
perineum by hooking the landmarks and drawing them together, 
and in seizing and fixing a portion of cervical tissue to be removed 
for the purpose of microscopical diagnosis. The slender tenaculum 
does not bruise the tissues as does the tissue forceps. 




Fig. 25.— Vulsellum 
Forceps. 



INSTRUMENTS AND THEIR USE 85 

The Vulsellum or Double Tenaculum Forceps. — In choosing an 
instrument of this sort one should aim at having it not too heavy 
and yet with steel enough to prevent the blades springing apart. 
The so-called American bullet forceps with two points, and having 
a check on one blade that prevents the blades crossing, is excellent 
and most useful. Vulsella made after the principle of Museaux's 
forceps (four points), or the French heavy vulsella (four or more 
points), are useful in the morcellation of fibroid tumors and the 
removal of cancer, but have no place in diagnosis. The double 
tenaculum forceps is useful in holding the cervix during dilatation 
when it is necessary to have a firmer hold than the single tenaculum 
will give, and in seizing pedunculated tumors in the vagina, also 
for holding and drawing down the uterus while practicing the 
bimanual touch to determine the relation of a tumor to this organ. 
(See Figure 126.) 

The Vaginal Speculum. — As has been said previously, most of the 
diagnosis in uterine diseases is made by the sense of touch. The 
vaginal speculum offers us a view of the vagina and vaginal portion 
of the cervix. Of the multitude of different forms of specula to 
be had of the instrument makers, the most generally useful are the 
bivalve and the Sims. The Edebohls speculum with weight 
attached is for use in curetting and manipulations performed with 
the patient anesthetized. In children a good view of the vagina 
may be obtained through a Kelly cystoscope, using as large a one 
as will go through the vaginal introitus without injuring the hymen, 
the patient being in the knee-chest position. 

The Bivalve or Duckbill Speculum. — There are many good forms 
of this speculum on the market. The writer prefers those called 
by the names of Brewer and Graves, because of their simplicity 
and usefulness under varying conditions. More than one speculum 
should be in every kit for the reason that vaginae vary so in size. 
With a girl having a narrow vagina and a not easily dilatable hymen, 
a small speculum is called for, whereas, for a woman having ex- 
tensive injuries of the pelvic floor and perineum and lax and 
redundant vaginal walls, a large speculum is a necessity. The 
patient is in the dorsal position. To introduce the bivalve speculum 
the left forefinger is anointed with lubrichondrin and both valves 
of the speculum are smeared with it. The forefinger is introduced 
into the vagina as in making the digital examination, the perineum 



86 PHYSICAL EXAMINATION 

is depressed, and the speculum introduced, the slit between the 
blades being vertical. Before the speculum has reached its deepest 
point of entrance it is turned so that the short blade is above and 
the long blade behind. By means of the lever connected with the 
handle of the speculum the blades are separated until the cervix 
is engaged between their ends, then they are held in place by the 
set-screw on the handle. Some bivalve specula, such as the Graves, 
are provided with a second set-screw with which to hold the sepa- 
rated bases of the blades, thus increasing the spread of the specu- 
lum at the introitus vaginae, and adding to its usefulness in cases 
of roomy vaginae. 

Care must be exercised, in handling the bivalve speculum, not to 
pinch folds of the vagina and the labia minora between the bases 
of the blades. This is most easy to do when the vagina is lax and 
the labia minora long. One objection to the bivalve speculum is 
that its blades cover both the anterior and posterior walls of the 
vagina, thereby obscuring them from view. This defect may be 
overcome in some cases by turning the speculum, first having 
loosened the lever holding the blades, so that the blades are on 
either side of the vagina. The cervix is to be brought into view, 
if it does not readily present, b}^ hooking a tenaculum in the os and 
drawing the cervix downward. 

The Neugebauer bivalve speculum and the Ferguson cylindrical 
speculum are used by some gynecologists. The latter covers the 
entire vagina and is of little value in diagnosis. The former re- 
quires much skill in handling to prevent pinching the vagina or 
labia, and when in place has no advantage over the duckbill specu- 
lum. 

There are various specula for use with the patient in the dorsal 
position that depress the perineum and posterior wall without 
covering the anterior wall, such as 

The Simon speculum, which is one-half of a Sims speculum. 
These specula are chiefly useful in operative procedures where the 
patient is anesthetized and is not called upon to endure the dis- 
comfort caused by prolonged traction on the perineum. For 
operative procedures the simplest and best speculum of this class 
is the Edebohls speculum with a solid flattened weight weighing 
about a pound and fitted with a hook, instead of the little 
pail usually sold with the speculum. The weight is made flat so 



INSTRUMENTS AND THEIR USE 



87 




Fig. 26. — Brewer Bivalve Speculum. 



that it does not take up useful space at the end of the operating 
table. A weight may be improvised easily out of a piece of lead 
pipe hammered flat and per- 
forated to take a hook made 
out of a piece of stout iron 
wire. 

The Sims Speculum. — This, 
when given to the profession a 
generation and a half ago by J. 
Marion Sims, transformed the 
art of gynecology, and is to be 
used only with the patient in 
the Sims position or in the 
knee-chest position. 

The orthodox method of pass- 
ing the Sims speculum is as fol- 
lows: — The operator holds the 
speculum by the unused blade 
in his left hand and places the 

well-anointed forefinger of the right hand, along the blade which 
is to be used, with the palmar surface of the finger fitting the con- 
cavity and the tip projecting just beyond the end of the blade. 

The tip only of the finger enters the 
vulvar cleft, and while the back of 
the forefinger protects the sensitive 
anterior wall of the vagina and in- 
troitus, the blade is pushed into the 
vagina by pressure from the thumb 
of the right hand on the base of the 
blade, the unused blade being at 
the same time transferred from the 
operator's left hand to the right 
hand of an assistant. 

Another and preferable way is to 

anoint the left forefinger as for a 

vaginal examination, except that 

the palmar as well as the dorsal surface of the finger is smeared 

with the lubricant, then, hooking the finger about the blade of the 

speculum, anoint it from base to tip. Finally, pass the same 




Fig. 27. — Graves Bivalve Speculum. 



88 PHYSICAL EXAMINATION 

finger over the vulvar cleft, introduce its tip into the vagina, and 
carry back the perineum far enough to allow the tip of the specu- 
lum to enter. In pushing the speculum home the direction of the 
vagina is to be borne in mind, its axis being not straight upward 
in the axis of the patient's body, but directed backward toward 
the sacrum. 

The use of the Sims speculum necessitates an assistant, except 
for a most cursory examination. The assistant stands on the left 
side of the table at the patient's back and faces squarely the 
physician, who is seated in the chair; with all the fingers of the 
left hand the assistant raises the labium majus on the upper, right 
side, holding it against the buttock with the hand flat, not with 
the ends of the fingers dug into the flesh. The assistant's left, arm 
rests on the patient's right thigh. The right hand receives the 




Fig. 28. — Sims Speculum. 

unused blade of the speculum after the other blade has been settled 
in the proper place in the vagina. The simplest method of holding 
the speculum, and the easiest for the novice to learn, is to grasp 
the unused blade with four fingers of the right hand, the palm of the 
hand being upward. (See Fig. 11, page 53.) 

With the speculum in position air enters the vagina and the 
pelvic contents gravitate toward the abdomen. Nothing but the 
posterior wall of the vagina being covered, a nearly unobstructed 
view of the vagina is afforded. By moving the speculum in or out 
or turning the tip from side to side, all parts of the vagina may be 
brought into view. If the vaginal walls are redundant some sort of 
a depressor will be found useful. For this purpose the best instru- 
ment is 

The Hunter Depressor. — It should have a flexible copper shank, 
and a large and a small end, and should be silver-plated. With it 



INSTRUMENTS AND THEIR USE 



89 



Fig. 29. — Hunter Vaginal Depressor. 



one pushes out of the field of vision the obstructing folds of the 
vagina. The Hunter depressor has an advantage over the Sims 
ring-shaped depressor in 
that its polished silver 
surface reflects light and 
therefore aids the specu- 
lum in illuminating the 
deep recesses of the vagina. In many cases the uterine dress- 
ing forceps, grasping a small piece of cotton, may be substituted 
for the depressor. The smallest speculum which 
will give a good view should be chosen because 
the small instrument does not stretch the hymen 
and introitus so much laterally, and thus a longer 
anteroposterior slit is opened in which the smaller 
speculum may be moved about freely. It is a 
mistake to use a large speculum in the case of a 
tight hymen or narrow vagina, because with it 
much less of the vagina can be seen and the patient 
is caused unnecessary suffering. The opening into 
the vagina should be oblong, not circular, and ad- 
ditional room is obtained only by carrying the 
posterior wall of the vagina backward. 

Looking into the vagina one confirms by sight 
the information gained by touch and gains addi- 
tional data. The rugae are seen, if present, con- 
ditions of inflammation are noted, also the caliber, 
length, and clilatability of the canal and abnormal- 
ities of shape and new growths. The character 
and amount of the discharge with its reaction, 
acid or alkaline; the cervix, its shape, size, loca- 
tion, whether lacerated, and if so, the situation 
and extent of the lacerations as determined both 
by sight and by use of the sound and tcnacula, 
also the cervical discharge, its character, amount, 
and reaction are all noted. Cover-glass specimens 
and cultures from the discharge may be made if necessary. 

The Emmet Curette Forceps. — This is one of the most valuable of 
the instruments used in diagnosis. With it one removes pieces of 
tissue from the uterine cavity for examination under the micro- 



Fig. 30.— Em 
met Curette For 
ceps. 



90 PHYSICAL EXAMINATION 

scope. It has many advantages over the curette, especially in 
cases of pedunculated growths which often are not caught by the 
curette. This instrument can not damage the uterine walls, as it 
does nothing more than pinch the bits of tissue which project 
above the surface of the endometrium. In selecting a curette 
forceps care should be exercised to have the jaws 
ground true so that they fit accurately together. 
Many of the instruments on the market are abso- 
lutely useless because the jaws have rounded edges 
which do not fit accurately one to the other over 
their entire length. In consequence the tissue which 
is engaged between them slips out and is not pinched 
tightly and removed as it should be. 

Except after labor or abortion the cervical canal 
must be dilated to a moderate degree with Hanks 
dilators in order to admit the closed jaws of the for- 
ceps. When once in the uterine cavity the jaws are 
separated and then brought together again. Then 
they are removed from the uterus and the contents 
washed off in sterile water. The process is repeated 
until the anterior and posterior walls of the cavity 
have been gone over thoroughly and systematically. 

The Uterine Curette. — One curette is sufficient for 
all purposes of diagnosis. This is a sharp loop of 
medium size, the shaft of the instrument being made 
of flexible copper so that it may be made to conform 
to a bent uterine canal. Also with a flexible shaft 
the danger of doing damage by too forcible curetting 
is lessened. Following abortion or delivery and when 
Uterine Cu- there i s flowing, the curette, and often the curette 
rette. forceps also, may be introduced through the cervical 

canal without dilatation, except under such conditions 
where dilatation is necessary. Curetting should only rarely be 
performed without an anesthetic. 

Curetting. — Instruments Needed. — Sound, vulscllum forceps, Ede- 

bohls speculum, Hanks dilators, Wathen dilator, curette, curette 

forceps, two uterine applicators, Bozcman's uterine douche with 

irrigator bag and tube. 

The patient is anesthetized with ether, either preceded by nitrous 




INSTRUMENTS AND THEIR USE 91 

oxide or not, according to the preference of the operator. She 
is placed in the lithotomy position on a Kelly pad with but- 
tocks at the edge of the examining table, 
the legs being held by an assistant or by 
portable or fixed leg holders. The biman- 
ual touch is practiced. The vulva, vagi- 
na, and surrounding regions are washed 
thoroughly with several washings of soap 
and hot water, then with alcohol, and final- 
ly with sterile water. Observe that the 
bimanual touch is made before the wash- 
ing up. This is because the tactile sense FlG 32 _Edebohls 
is less interfered with when the vagina is Vaginal Speculum, 

lubricated by the natural secretions. Af- 
ter irrigation and swabbing with alcohol, and especially with solu- 
tions of corrosive sublimate, the vagina is dry and clings to the 
finger, sometimes to such a degree that the sense of touch is very 
much blunted. Sterile towels are placed about the 
field of operation and an Edebohls weighted specu- 
lum, previously sterilized with the other instru- 
ments, is introduced into the vagina. The anterior 
lip of the cervix is seized with a double tenaculum 
forceps and the sound is passed. (For facts to be 
learned by the passing of the sound see page 80.) 
The cervix is dilated by passing the graduated 
Hanks metal dilators. These are safer than the 
branched steel dilator, which, if carelessly used, 
makes rents in the uterine walls, more especially 
in the neighborhood of the internal os. These rents 
are not always recognized by the operator. 

If the cervix is rigid it is well to follow the Hanks 
dilators with a steel branched dilator. The Wathen 
dilator is one of the best of these. After it has been 
^' TT 33 '. - introduced the blades are to be separated by approx- 
Dilator. imating the handles by manual pressure, not by 

turning the set-screws, as is so often done. The 
reason for this is that when using the screw the operator can 
not judge of the force he employs, whereas, by manual pres- 
sure, he can estimate it accurately. When sufficient power 



92 



PHYSICAL EXAMINATION 



has been applied the screw is turned until the handles are held 
in place. After the uterine muscle is tired the handles are brought 

a little nearer together and the screw 
•takes up the slack. — thus relieving the 
operator's hands. Fifteen minutes are 
necessary for dilatation, more if the 
dilatation is to be excessive, as in cases 
where it is best to insert the finger into 
the uterine cavity for purpose of ex- 
ploration. Dilatation being accom- 
plished, the curette is introduced and 
the walls of the uterine cavity are gone 
over systematically, an- 
terior wall, posterior wall, 
lateral sulci, fundus, and 
region of the internal 
os. The curette forceps 
always supplements the 
curette and many are the 
polypi which have escaped 
the curette that are seized 
by the curette forceps. 
The ' curetting should be 
stopped when the curette 
grates on the firmer sub- 
mucous tissue of the uter- 
ine wall. The feeling im- 
parted to the curette is 
characteristic. The pieces 
of tissue obtained are col- 
lected from the vagina on 
swabs of wet sterile gauze 
held in the dressing for- 
ceps and transferred at once to a ten-per-cent formalin 
solution, in which they are preserved for the path- 
ologist. The uterine cavity is irrigated freely with 
hot sterile water or hot salt solution and swabbed 
dry with gauze wound around a uterine applicator, 
uterine douche is as good as any for purposes of ii 




Fig. 



34.— Wathen 

Dilator. 



Uterine 



Fig. 35.— 

Bozeman- 
Fritsch Uter- 
ine Irrigator. 

Bozcman's 
the 



•igating 



INSTRUMENTS AND THEIR USE 



93 



uterine cavity, though in cases of long and rigid cervix, the 
Burr-age uterine speculum is useful both for irrigation and for 
swabbing the uterine interior. For packing the uterine cavity 
with gauze, a procedure sometimes necessitated in obstinate 
hemorrhage, this latter instrument is invalu- 
able, for the gauze slips easily through the 
metal tube of the speculum into the uter- 
ine cavity instead of clinging to the tissues 
of the cervical canal. 

The vagina is now protected by placing a 
pledget of sterile gauze in the posterior vagina 
under the cervix, and the uterine cavity 
is swabbed out with a uterine applicator 
wound with gauze and dipped in pure car- 
bolic acid. This swabbing 

serves a triple purpose : — it an- 

tisepticizes the uterine cavity, 

thus providing for possible 

errors in technique; it mildly 

cauterizes the uterine interior, 

thus checking hemorrhage ; and 

it destroys the little islands of 

tissue which have been missed 

by the curette. By studying 

the interior of uteri which have 

been removed by hysterectomy 

— a previous curetting without 

swabbing having been done — it 

has been my experience to find 

that there are nearly always 

present at least one or two bits 

of adventitious tissue left behind by the curette. 
The Dangers of Curetting. — These are: (1) per- 
foration of the uterus, a very considerable danger 
in septic conditions and after labor; (2) hemorrhage, especially 
after labor or abortion when the uterine sinuses are large; (3) the 
removal of the entire endometrium and submucous layer prevent- 
ing regeneration and causing the formation of scar tissue and 
subsequent sterility; and (4) septic infection from the inocula- 




Fig. 36. — Burrage 
Uterine Speculum. 



Fig. 37.— 
Uterine Ap- 
plicator. 



94 



PHYSICAL EXAMINATION 



tion of the endometrium with septic matter already there or in- 
troduced from without. Perforation is avoided by using the great- 
est gentleness in curetting septic cases and in using the curette 
forceps or the finger instead of the curette wherever possible. 

If hemorrhage occurs, the uterine cavity is to be irrigated with 
very hot water (120° F.), and, this failing, it is to be packed with 
gauze. For this purpose a Burrage uterine speculum and forked 

pusher will be found 
most useful. The re- 
moval of the entire 
endometrium and sub- 
mucous layer is avoid- 
ed by observing the di- 
rections already given, 
and the production of 
septic infection by ob- 
serving strict asepsis 
and by not operating 
during acute attacks 
of pelvic inflamma- 
tion. 

Digital Exploration of 
the Uterine Cavity. — 
This is practiced ordi- 
narily for complete in- 
vestigation in cases of 
doubt. The dilatation 
is effected by means of 
the Hanks dilators, fol- 
lowed by the Wathen 
dilator. The Bossi uterine dilator or large steel rectal dilators are 
useful for the extreme stages of the dilatation. The bare finger 
should be employed for the exploration because thus the full ben- 
efit of the tactile sense is to be obtained. In exceptional cases, 
those with rigid cervices where danger of rupture of the tissue is 
great, a valuable method of exploring the uterine cavity is that 
described most fully in Dr. Howard A. Kelly's " Operative Gyne- 
cology," Second Edition, Vol. I., page 596. An anterior colpotomy 
is performed, the transverse incision being used. After the vagina 




Fig. 



38. — Transverse Incision Anterior to 
Cervix. (Kelly.) 



INSTRUMENTS AND THEIR USE 



95 



and bladder have been separated from the uterus by blunt dis- 
section, the cervix is steadied by two vulsella and the anterior lip 
of the cervix is divided between them with scissors to a point 
beyond the internal os. The digital examination of the uterine 
interior completed, the divided uterine walls are brought together 
with sutures and the vagina is then replaced and sutured. In my 
experience, a certain amount of preliminary dilatation of the cervix 
facilitates this opera- 
tion. (See Figs. 38-41.) 

The remaining in- 
struments in the ex- 
aminer's kit, namely, 
those for the investi- 
gation of the urethra, 
bladder, and ureters, 
and those for the ex- 
amination of the rec- 
tum, will be described 
in the succeeding chap- 
ters devoted to these 
subjects. 

Pelvimetry. — The 
gynecologist is fre- 
quently consulted by 
women who wish to 
know whether they 
have any pelvic de- 
formity that would be 
a hindrance to their 
having children, also 
by those who are already pregnant with the same query, there- 
fore it seems best to describe the measurement of the pelvis. B. 
C. Hirst ("Diseases of Women," p. 419) thinks that deformed 
pelves occur in about seven per cent of the white women of large 
American cities, but that they are comparatively infrequent among 
the upper classes and in the rural agricultural districts, while 
frequent among negroes. A general practitioner in a city can 
hardly hope to avoid seeing cases of pelvic deformity. For the 
many forms of pelvic deformities the reader is advised to consult a 




Fig. 39. — Incising the Anterior Wail of the 
Cervix. (Kelly.) 



96 



PHYSICAL EXAMINATION 



modern text-book on obstetrics. The commonest forms are simple 
flat pelvis, generally equally contracted pelvis (justo-minor), and 
generally contracted flat pelvis. These are all due to faulty devel- 
opment of the skeleton. The other rarer forms are caused by 
disease of the pelvic bones and anomalies in the sacro-iliac and 
pubic joints. 

To practice pelvimetry successfully one must have a reliable 
tape measure and a pelvimeter. The latter is a large pair of 

calipers with a scale divided into cen- 
timeters and inches. The measure- 
ments to be made are the antero- 
posterior diameter of the superior 
strait, the capacity of the pelvic cav- 
ity, and the transverse diameter of the 
pelvic outlet. In exceptional cases of 
obliquely contracted pelvis it may be 
necessary to measure the oblique di- 
agonal diameters of the pelvic inlet. 
The patient must be prepared as for a 
vaginal examination and should be in- 
spected first in the standing position to 
note the posture, shape of the back, 
and inclination of the pelvis. 

External or Baudelocque' 's Conjugate 
Diameter (8 inches, or 20.5 centi- 
meters). — On inspecting the standing 
woman from behind, one sees in some 
cases, not in all, Michaelis' rhomboid, 
a lozenge or diamond-shaped surface 
on the skin at the base of the spine. 
The four points making the diamond 
are: — on the sides, a depression at each upper corner of the 
sacrum; at the bottom, the notch between the buttocks; and 
at the top, the depression over the spine of the fifth lumbar ver- 
tebra. If this depression can not be seen, the spines of the 
vertebrae are felt by the finger from above downward until the 
last one is reached. The tip of the pelvimeter, guided into place 
by the physician's finger, is placed in the depression just below 
the last spine. The other point of the pelvimeter is placed on 




Fig. 40. — Uterine Cavity Laid 
Open. (Kelly.) 



INSTRUMENTS AND THEIR USE 



97 



the anterior upper margin of the symphysis pubis, exactly in 
the middle line. Firm pressure is made and the reading on the 
scale of the pelvimeter is taken. The true conjugate can not be 
estimated accurately from the external conjugate because of the 
uneven thickness of the pelvic 
bones in different individuals, 
and also because of the varying 
obliquity of the pubic bone. An 
external conjugate of 6 \ inches, 
16 centimeters, or under, means 
surely an antero-posterior con- 
tracted pelvis, anything over 8 
inches, 20.5 centimeters, is nor- 
mal or large. 

The oblique conjugate diameter 
(5 J inches, or 12.8 centimeters), 
or the distance from the prom- 
ontory of the sacrum to the 
under margin of the symphysis 
pubis, may be measured by ex- 
amining the woman in the dorsal 
position. Two fingers of the left 
hand are introduced into, the va- 
gina and the middle of the prom- 
ontory of the sacrum reached 
with the tip of the middle finger. 
Be careful not to mistake the last 
lumbar for the first sacral ver- 
tebra and be gentle and not too 
rapid in performing this ma- 
nipulation. With the tip of the 
forefinger of the right hand, 
mark the point at the base of 
the thumb of the left hand 
touched by the lower edge of the symphysis. After the hand has 
been removed, the distance between the tip of the middle finger 
and this point is measured by the tape measure. Subtract from 
this I of an inch, or 1.75 centimeters (representing the thick- 
ness of the symphysis), to obtain the true conjugate. The 
7 




Fig. 41. — Exploring Uterine Cavity 
with Finger. (Kelly.) 



98 



PHYSICAL EXAMINATION 



measurement of the normal true conjugate is 4f inches, or 11 
centimeters. 

The transverse diameter (5| inches, or 13.5 centimeters). — This 
diameter is inferred from measurements of the iliac bones. The 
distance between the anterior superior spinous processes of the 
ilia in well-formed women is 10J inches, or 26 centimeters; the 
distance between the crests of the ilia at their widest points is 11 J 

inches, or 29 centimeters; the dis- 
tance between the trochanters is 
12J inches, or 31 centimeters. In 
making these measurements the 
patient is in the dorsal position, 
but with the thighs extended. 

The Transverse Diameter of the 
Outlet (4| inches, or 11 centime- 
ters) . — This is the distance between 
the tuberosities of the ischia and 
is measured with the patient in 
the lithotomy position, the pelvi- 
meter being employed as in the 
other external measurements. 

The Capacity of the Pelvic Cav- 
ity. — This is an estimate formed 
by vaginal examination with two 
ringers in the vagina. When the 
oblique conjugate is being measured the opportunity should be 
seized to palpate the interior of the pelvis and form an idea of its 
capacity, as well as a search made for abnormalities in the shape 
of new growths, old fractures, caries, or necrosis. 

The Oblique Diagonal Diameters (8| to 9J inches, or 22 to 23 
centimeters). — These are measured by the pelvimeter with the 
patient lying first on one side and then on the other. One end of 
the pelvimeter is placed on the posterior superior iliac spine on one 
side and on the anterior superior iliac spine on the other. The 
right oblique diagonal is generally a trifle longer than the left. 
The posterior superior spinous processes are often marked by 
distinct dimples on the woman's back. 




Fig. 42.— The Pelvimeter. 



CHAPTER VIII 

THE INVESTIGATION OF THE URETHRA, BLADDER, AND 

URETERS 

Instruments used, p. 99. 

Anatomy, p. 100. The urethra, p. 100. The bladder, p. 101. Land- 
marks in the bladder, p. 102. The ureters, p. 104. 

The examination, p. 107. Catheterization of the bladder, p. 108. Search- 
ing the urethra and the bladder, p. 108. Direct endoscopy and cystoscopy 
with air distended urethra and bladder, p. 110. Catheterization of the 
ureters, p. 115. Indirect cystoscopy with water distended bladder, p. 117. 
Chromocystoscopy, p. 119. 

In this chapter we will consider only direct urethroscopy and 
cystoscopy by means of a simple tube (the Kelly cystoscope) and 
reflected light, as a means for the inspection of the urethra and 
bladder, for it has been found in the author's experience, to meet 
satisfactorily the gynecologist's requirements for diagnosis. More- 
over, the method is easily learned and simpler than cystoscopy with 
a Nitze cystoscope or instrument of that class, by which an electric 
lamp is introduced into the water-distended bladder. As indirect, 
electric cystoscopy is applicable occasionally where the air-dis- 
tended bladder method cannot well be used, and as many physicians 
prefer it as a method of diagnosis, I have added as an appendix a 
description of the steps of this sort of cystoscopy as I have seen it 
employed in competent hands. 



INSTRUMENTS USED 

Silver female catheter, long. 

Kelly meatus calibrator. 

Kelly steel urethral sounds, one set. 

Kelly cystoscopes, Nos. 8, 10, and 12. 

Kelly ureteral searcher. 

99 



100 THE URETHRA, BLADDER, AND URETERS 

Two Kelly ureteral catheters . 

Rubber bulb and tube for suction. 

Alligator bladder forceps. 

Uterine applicator. 

Sims speculum. 

Head mirror. 

To this list of instruments are added: 

A sterile ten-per-cent solution of cocaine hydrochlorate in water. 

A sterile four-per-cent solution of boric acid. 

Absorbent cotton. 

A sterile eight-ounce bottle with stopper. 

Two sterile two-ounce bottles with stoppers. 

A two-quart fountain syringe, and a 

Collapsible tube of lubrichondrin, or K-Y jelly. 

Not every woman who complains of urinary symptoms is to be 
subjected to a cystoscopic examination. For instance, frequency 
of micturition associated with early pregnancy, although not pre- 
cisely normal, generally represents increased congestion of the 
upper urethra and the neck of the bladder, due to the pregnant 
state, and is to be disregarded, unless the symptoms are so severe 
that they undermine the health by interfering with rest and sleep. 
Only when urinary symptoms are persistent as well as severe, are 
the urinary organs to be investigated. 

Before proceeding to the examination let us review the salient 
features of the anatomy of the urethra, bladder, and ureters. 



ANATOMY 

The Urethra. — The urethra is a membranous canal varying 
from an inch and a quarter to an inch and a half in length 
(3 to 3.5 centimeters) extending from the meatus urinarius to 
the neck of the bladder. It lies under the arch of the pubes, 
its lower extremity being separated from the pubic bone by 
about four-tenths of an inch (1 centimeter). It is parallel with 
the vagina and is embedded in its wall, its course being slightly 
curved, the concavity directed forward and upward. Its diame- 
ter when undilated is about a quarter of an inch (6 millimeters). 



ANATOMY 



101 



The meatus urinarius opens into the vestibule just above the open- 
ing of the vagina. 

In virgins the meatus is a vertical slit about a fifth of an inch 
long, formed by two little lips which close the orifice and protect 
it from infection. In old women these lips are 
lacking. 

The wall of the urethra consisting of three 
coats, muscular, erectile, and mucous, is about one- 
fifth of an inch thick and is dilatable to a consider- 
able degree, the meatus being the most resistant 
part. It is not safe, however, to dilate the urethra 
beyond twice its normal diameter, i.e., beyond half 
an inch (12 millimeters), because of 
the danger of permanent inconti- 
nence of urine. 

When the urethra is not distended 
the mucous coat is thrown into 
longitudinal folds, one of which, 
placed along the floor of the canal, 
resembles the verumontanum in the 
male urethra. The canal is lined 
with stratified epithelium, which be- 
comes transitional near the bladder. 
In the floor of the urethra are 
two little tubular glands, half an 
inch long and about a thirty- 
second of an inch in diameter, 
placed length-wise, with their ori- 
fices at the meatus, just within or 
upon the labia urethra?. These 
are Skene's glands. It is thought 
that the function of these glands 
is to secrete a lubricating mucus to protect the 
meatus from trauma during coitus. 

The Bladder. — The bladder, a musculo-mem- 

branous sac embedded in connective tissue, when 

quite empty and contracted is cup-shaped, and 

on vertical median section its cavity, with the adjacent portion of 

the urethra, presents a Y-shaped cleft, the stem of the Y corre- 



Fig. 43.— 
Silver Female 
Catheter. 



Fig. 44.— Kel- 
ly Meatus Cali- 
brator. 



102 



THE URETHRA, BLADDER, AND URETERS 



sponding to the urethra. When slightly distended the bladder 
has a rounded form and is still contained within the cavity of 
the pelvis ; when greatly distended it is ovoid in shape, rises 
into the abdominal cavity, and may reach as high as the 
umbilicus. Its capacity is about a pint. 

For purposes of description the bladder may 
be divided into a superior, an antero-inferior, 
and two lateral surfaces, also a base or fundus, 
and a summit or apex. 

The superior, or abdominal surface, is free 
toward the peritoneal cavity and is covered 
with peritoneum; the antero-inferior portion 
looks toward the posterior surface of the sym- 
physis pubis and is uncovered by peritoneum; 
the lateral surfaces are covered by peritoneum 
except in their lower portions where they come 
in contact with the broad ligaments; the fundus 
or base of the bladder is directed downward and 
backward and is partly covered by peritoneum 
and partly uncovered. It is connected with the 
anterior aspect of the cervix and with the an- 
terior wall of the vagina by areolar tissue, the 
union between the bladder and vagina being 
closer than that between the bladder and cer- 
vix. The upper portions of the bladder are more movable 
than the lower and when viewed through the cystoscope may 
be seen to move with respiration. 
The so-called neck of the bladder is the point of beginning 
of the urethra, but it is not a 
true neck, as there is no 
tapering part. A 
tonic contrac 
tion of the 
muscular 
fibers in 

the bladder wall at this point prevents the 
escape of urine. 
The bladder is composed of four coats: 
Fig. 46.— Kelly Evacuator. serous, muscular, submucous, and mucous. 



Fig. 45.— The 
Kelly Double- 
ended Urethral 
Dilator. 





Fig. 47. — Kelly Ure- 
teral Searcher. 



ANATOMY 



103 



The serous coat is derived from the peritoneum and 
is therefore partial; the muscular coat is made up of 
three layers of unstriped muscular fibre, two of them 
being longitudinal, and one, circular in direction; the 
submucous coat is the areolar tissue which connects 
the muscular with the mucous coat. The mucous coat 
is thin, smooth, and of a pale rose color, and is thrown 
into folds or rugae when the bladder is empty. There 
are no true glands in the mucous membrane. 

Landmarks in the Bladder. — When the bladder is 
distended with air it forms a hollow sphere. The in- 
ternal orifice of the urethra or neck of the bladder is 
a definite landmark to be recognized by the observer 
looking through the cystoscope as the first portion 
of mucous membrane which rolls into the lumen of 
the cystoscope as its end is withdrawn through the 
urethra. The ureteral orifices are two minute open- 
ings situated in small elevations of the mucous mem- 
brane of the bladder (mons ureteris), an inch apart, 
one on each side of the median line and each three- 
quarters of an inch (2 centimeters) from the internal 
orifice of the urethra. These three points mark out 
the trigone of the bladder. 

There is sometimes seen the interureteric liga- 
ment, a distinct fold elevated above the level of 
the surrounding mucosa connecting the ureteral 
orifices. 

The location of lesions in the bladder is described 
by means of these landmarks and by the natural 
divisions of the bladder already given. 

The Ureters. — The ureters are two cylindrical mem- 
branous tubes lying in the loose connective tissue 
behind the abdominal and pelvic peritoneum, about 
three-sixteenths of an inch (6 millimeters) in diameter 
and twelve inches (30 centimeters) long, extending 
from the pelvis of the kidneys to the bladder. The 
length of the ureters depends in some measure on the 
length of the trunk. A patient having a long trunk 
will have correspondingly long ureters. Different 



K 



....v.. 

Fig 
Kell 
tera 
eter. 



.1 

. 48.— 
y Ure- 
1 Cath- 



104 



THE URETHRA, BLADDER, AND URETERS 



authorities give the length of the ureters all the way from ten to 
sixteen inches (25 to 40 centimeters). The left ureter is a little 
longer than the right because of the higher position of the left 
kidney. The ureter is funnel-shaped as it leaves the pelvis of the 
kidney and then the lumen has a diameter of an eighth of an 
inch (2 millimeters), until the ureter reaches its termination in 
the bladder wall, where there is a narrowing, which becomes a 
complete closure when the bladder is distended. This closure 




Fig. 49. — Kelly Cystoscope with Obturator. 

is effected by the oblique insertion of the ureter in the bladder 
wall, the mucosa and anterior portion of the bladder wall forming 
with the upper side of the ureter a wedge-shaped valve, the apex 
of the wedge being at the ureteral orifice. 

The ureter lies on the psoas muscle throughout its abdominal 
course, at the brim of the pelvis it lies on the common iliac 
artery. Within the pelvis it runs downward just outside the in- 
ternal iliac artery, and then, turning forward and crossing under 
the uterine artery, it passes half-way between the pelvic wall and 



ANATOMY 105 

the cervix, at a distance of about half an 
inch from the latter, under the base of the broad 
ligament to the bladder. The ureter is com- 
posed of three coats, fibrous, muscular, and mu- 
cous. The fibrous coat is continuous with the 
capsule of the kidney above and- is lost in the 
bladder wall below; the muscular coat of the 
ureter proper is made up of three layers: exter- 
nal, internal longitudinal, and middle circular; the 
mucous coat is smooth and has a few longitudinal 
folds. It is continuous with the mucosa of the 
bladder below and the pelvis of the kidney 
above, and is composed of several layers of cells. 

The ureters transmit the urine from the kid- 
neys to the bladder intermittently by means of 
peristaltic waves traveling the length of the 
ureter. Through the cystoscope the urine may 
be seen to issue from the ureteral orifices in 
little spurts and the ureteral orifices may be 
seen to expand and contract, the spurts being 
more forcible and more frequent with greater 
activity of the kidneys, the normal rate being 
all the way from one spurt every ten seconds 
to a spurt every sixty seconds. 

Observations have been recorded which tend to 
prove that the movements of the orifice are less 
frequent when the kidney on that side is func- 
tionally inactive. Infection 
travels from the bladder up 
the ureter only when the 
valve-like arrangement at 
the orifice in the bladder 
has been destroyed, or 
when infective material 
has been introduced into 
the ureter, as on a ureteral 
catheter Or bougie. FlG# 5 0.-Alligato7Bladder Forceps. 



106 



THE URETHRA, BLADDER, AND URETERS 



THE EXAMINATION 

Suppose a woman presents herself complaining of marked pain 
or difficulty with urination, or she has noticed pus or blood in the 
urine. The examination is conducted as follows: The patient 
is instructed not to pass her urine, if she is able to hold it. She is 
placed on the table in the dorsal position (see page 33). The 




Fig. 51. — The Normal Bladder, Laid Open from the Front. (Kelly.) 

external genitals are inspected and a sharp lookout is exercised for 
evidences of gonorrhea, for eczematous skin lesions, or abnormali- 
ties of the meatus. 

Redness about the meatus and the orifices of the glands of 
Skene and Bartholin, with the possibility of expressing a drop 
or two of pus from the urethra by stroking its course through 



THE EXAMINATION 107 

the wall of the vagina, makes gonorrhea most probable. Gon- 
orrhea being suspected, no instrument should be passed beyond 
the bladder neck for fear of carrying infection into that organ. 

Inspection shows whether the labia urethrse, which normally 
close the meatus in virgins, are in apposition or separated ; shows 
the presence of a urethral caruncle or prolapse of the mucous 
membrane of the urethra or a tumor in the urethra projecting 
through the meatus. Inspection also shows eczema of the vulva 
caused by the urine of diabetes mellitus. 

Palpation by the left forefinger in the vagina reveals thickening 
of the urethra and tenderness at any portion of its course, also a 




Fig. 52. — Urine Spurting from Ureteral Orifice, as Seen through Cystoscope. 

(Knorr.) 

suburethral abscess or tumor, and the bimanual touch reveals 
thickening of the bladder walls, a stone in the bladder, points of 
tenderness, a distended bladder, or a vesico-vaginal fistula. Per- 
cussion over the pubes determines an area of dullness corresponding 
to a distended bladder. The bimanual touch may reveal tenderness 
of the pelvic portion of the ureter or thickening of the ureter in this 
part of its course, or a stone in the ureter. 

To reach the upper portion of the pelvic portion of the ureter the 
recto-abdominal bimanual touch is best. Thin and relaxed ab- 
dominal walls are a necessity for success in this field of investiga- 
tion, although a thickened ureter may be palpated in the lowest 
two inches of its course by a digital vaginal examination, and, 
exceptionally, a thickened ureter may be seen as a ridge in the 



108 THE URETHRA, BLADDER, AND URETERS 

vaginal mucous membrane on speculum examination of the vagina. 
Palpation having furnished what information it will, the next step 
is the passage of the silver catheter. 

Catheterization. — I prefer a long catheter of small caliber, because 
it may be used both as a searcher of the urethra and bladder as 
well as a catheter. The meatus, vestibule, and inner surfaces of 
the nymphse are sponged with three or four pledgets of cotton 
soaked in sterile water or weak creolin solution, each pledget being 
thrown away as soon as it has been used once. That is, a piece of 
cotton is never dipped a second time in the water. Normally the 
urethra, as in the case of the vagina, except just inside the external 
opening, is free from bacteria. Well lubricated, the sterile catheter 
is passed gently into the bladder, the direction of the urethra being 
borne in mind, at first backward parallel with the axis of the 
vagina until the bladder neck is reached, and then forward. Care 
should be taken not to touch the outer end of the catheter before 
the urine is collected, and the lubricating should be done directly 
from the collapsible tube without the intervention of the physician's 
fingers. 

The urine from the bladder is collected in the sterile eight-ounce 
bottle for analysis, note being made of the character of the urine 
as it flows from the catheter, whether clear, cloudy, or bloody. 
Blood at the beginning indicates that its source is the ureter or kid- 
ney. Also whether the last part is cloudy, showing residual pus; 
and the force of the stream, increased in distended bladder and in 
cases of pressure on the bladder by tumors or straining, decreased 
in atonic bladder. Suprapubic pressure may be necessary to 
empty such a bladder. 

Searching the Urethra and Bladder. — After the urine has been 
withdrawn the catheter is used as a searcher, the greatest gentleness 
being employed. The bladder walls are gone over systematically 
and points of tenderness noted. With a finger in the vagina and 
the searcher catheter in the bladder the thickness of the bladder 
wall at the base is estimated; a stone, foreign body, or phosphatic 
deposits are detected by a gritting sensation transmitted to the 
catheter, or, in the case of a stone, by a metallic click; sometimes 
a tumor is diagnosed in this way. In cases of cystitis it is not wise 
to sound the bladder at the same time that a cystoscopic examina- 
tion is to be made because the slightest trauma will cause bleeding. 



SEARCHING THE URETHRA AND BLADDER 109 

The discharge of blood through the catheter at the end of catheter- 
ization is a diagnostic sign of cystitis. 

If there is suspicion that the bladder is contracted, its capacity 
may be measured by injecting with the fountain-syringe tube 
attached to the catheter, warm, sterile, one-per-cent boric-acid 
solution until the patient has a strong desire to urinate. Then 
disconnect the syringe tube and collect and measure the water 
issuing from the catheter. In cases of cystitis it is wise to irrigate 
the bladder with boric-acid solution before ending the examination. 
For this purpose the process just described is repeated several times. 
It is to be noted that the catheter has not been removed from the 
bladder since it was introduced, thus a minimum of trauma is 
inflicted on the urethra and vesical neck. 

The bladder searching being finished, the catheter is withdrawn 
slowly; clonic spasm of the bladder walls is noted in some cases, 
indicated by a drumming of the movable upper portion of the 
bladder on the less movable base. If the bladder is irritable or the 
muscular fibres hypertrophied, the catheter is seized with greater 
firmness at the bladder neck as it is withdrawn. 

When the end of the catheter reaches the urethra one notes: 
points of tenderness, pouches in the mucous membrane or abnormal 
size in the lumen, also stricture, by no means rare, its situation and 
relative size. With a finger in the vagina and the end of the 
catheter in the urethra one determines the thickness of the walls of 
the urethra, the extent of any pouching of the mucous membrane, 
due to rupture of the walls from trauma during delivery, and also 
dislocation of the urethra downward. This is a common deformity 
and one often overlooked. To detect it the investigator observes 
whether the urethra is in close relation with the under surface of 
the arch of the pubes as it should be normally, or far away from it, 
as it is when dislocated. In cases of prolapse of the uterus the 
urethra, together with the bladder, is commonly dislocated to a 
variable degree. Suppose the upper third of the urethra is dis- 
located downward with the bladder. The catheter is passed into 
the urethra most gently until it meets the obstruction of the down- 
ward bend of the urethra. The point of the catheter is noted by 
palpation by a finger in the vagina and thus the situation of the 
beginning of the dislocation is determined. 

In the case of procidentia, if the bladder is dislocated a curved 



110 THE URETHRA, BLADDER, AND URETERS 

uterine sound is to be substituted for the catheter and the situation 
of its point, as felt by the finger ; marks the lower limits of the 
bladder in the prolapsed mass. 

Having gained all the facts possible by the use of the catheter, 
the next proceeding is inspection of the urethra and bladder. 

Direct Endoscopy {Inspection of the Urethra), and Direct Cysto- 
scopy {Inspection of the Bladder). — The patient is in the dor- 
sal position. The bladder has been emptied of urine. The 
tip of the meatus calibrator is passed into the urethra and the 
size of the undilated meatus is read on the scale of the calibrator. 
Suppose it reads 6 millimeters. A No. 10 cystoscope may 
be used and the meatus must be dilated a little. This should be 
done by gentle pressure on the conical calibrator and twisting it, 
care being taken that the lubrication is ample. If the tissues 
about the meatus prove to be rigid it is wise not to make all of the 
dilatation at one sitting, for the patient's confidence will be lost if 
she is hurt too much. If there is a stricture of the urethra it must 
be dilated with the double-ended steel dilators, and the dilatation 
should occupy several sittings. The meatus being stretched to 
10 millimeters without laceration or excessive pain to the patient, 
the next step is the cocainization of the urethra. Sometimes, if 
the meatus is sensitive, it will be found best to use the cocaine 
before dilating the meatus. 

To cocainize the urethra wet the terminal two inches of the uterine 
applicator and wrap it, using a sterile rubber glove to handle the 
cotton, with a thin layer of absorbent cotton so that the diameter 
of the wrapped applicator is about three-sixteenths of an inch 
(4 millimeters). Soak this in sterile ten-per-cent cocaine solution 
gently insert the applicator into the urethra, hold the cotton at 
the meatus with two fingers while the applicator is withdrawn with 
the other hand, leaving the cotton in the urethra. 

It is well not to pass the tip of the applicator beyond the neck 
of the bladder, because if this is done ardor urinse is likely to be 
evoked and, the cotton acting as a wick, urine will drip from the 
end projecting from the meatus, thus diluting the cocaine and 
soiling the patient's clothing while she is being put in the knee- 
chest position for the cystoscopy. 

A knee-chest position, modified from that described on page 
56, is the one commonly employed for cystoscopic examinations. 



DIRECT CYSTOSCOPY 



111 



In this case the thighs are not vertical as in the correct knee- 
chest position, the knees being nearer the chest. In very stout 
patients and in certain operative cases the raised pelvis position 
(page 58) is employed. By the time all the instruments are 
ready, the room is darkened, and the patient is well settled in the 
correct knee-chest position (four or five minutes), the cocaine 
should have produced sufficient anesthesia of the urethra to permit 
us to proceed with the cystoscopy. 

Artificial light is necessary for cystoscopy. An electric light, 
gas light, or a kerosene lamp is to be chosen in the order named. 
The ordinary sixteen-candle-power electric lamp is sufficient, a 




Fig. 53. — Modified Knee-chest Position Used in Cystoscopy. B. Is position of 
Buttocks in the Modified Position. 

thirty-two-candle-power lamp with a tin reflector is better. An 
argand burner makes the best gas light, but a Welsbach light is 
good. A kerosene lamp must have a circular burner so as to give 
a large flame. Any lamp should have the shortest possible stand so 
that the source of light may be as near to the patient's sacrum as 
possible, in order that the angle formed at the mirror on the opera- 
tor's forehead between the rays from the source of light and the 
reflected rays going into the bladder may be as acute as possible. 
It should be remembered that the electric light, if held near the 
uncovered skin for any length of time, will cause a serious bum. 
If the patient is anesthetized this is a very important fact to bear 
in mind. 



112 



THE URETHRA, BLADDER, AND URETERS 



Light reflected by a head mirror from an ample source is far 
better as an illuminant of the bladder than light from a small 




Fig. 54. — Bladder, Vagina, and Rectum Ballooned by Air Admitted with Pa- 
tient in Knee-chest Position. (Kelly.) 

electric headlight, because it is difficult to keep the field illuminated 
with the small light, every motion of the head deflecting the rays. 



DIRECT CYSTOSCOPY 



113 



Any form of illumination introduced into the bladder obstructs 
the view, the wires for the lamp cutting off a part of the lumen of 
the urethra, besides the risk of burning the bladder by the heat 
generated by the lamp. 

All being in readiness, the pledget of cocaine-soaked cotton is 
removed from the urethra and a well-lubricated No. 10 cystoscope 
with its obturator in place is passed into the urethra and bladder. 
If air does not enter the vagina it is well to open the introitus 




Fig. 55. — Suction Apparatus in Use for Removing Urine from Bladder. (Kelly.) 



vaginae with one finger. If the bladder does not balloon at once, 
the silver catheter, previously cleaned and lubricated, is passed 
through the sphincter ani, thus letting air into the rectum, and 
permitting the trigone of the bladder to come more into view 
through the cystoscope. 

The operator sits on a high stool and looks through the cysto- 
scope, which should be practically horizontal if the patient is in the 
proper position. 
8 



114 THE URETHRA, BLADDER, AND URETERS 

If urine has collected in the superior portion of the bladder, or 
if it collects during the examination, it is to be removed by the 
bent tube introduced through the cystoscope, suction being applied 
by means of the bulb and rubber tube attached to the tube in the 
bladder. The greatest care should be exercised to have the bulb 
and tubes sterile, so that infection may not be introduced, and to 
this end the bulb should be squeezed and held collapsed while the 
end of the tube is rinsed in sterile water before it is introduced. 
A modified chemical-laboratory wash-bottle may be used for re- 
moving the urine, as shown in figure 55. 

In cystoscopy with the patient in the elevated-pelvis position 
the collection of urine at the fundus of the bladder is much more 
troublesome than it is when the patient is in the knee-chest position, 
for in the latter position the urine falls into the capacious superior 
part of the bladder behind the pubes. 

The different landmarks of the bladder are sought for, the 
ureteral orifices inspected. Bits of tissue may be removed from 
ulcerated areas or new growths with the alligator forceps; cultures 
taken, or the ureters catheterized. Of the last, more shortly. 

A culture is taken by bending the handle of a sterile cotton- 
tipped uterine applicator so that the applicator will pass through 
the cystoscope without obstructing the view. After the desired 
area in the bladder has been swabbed with the cotton, the latter 
is drawn over the surface of the slant agar tube, hydrocele agar 
being used when gonococcus infection is suspected. 

To find the ureteral orifices first determine the situation of the 
internal opening of the urethra. This is done by noting the point 
at which the urethral mucous membrane begins to roll into the 
lumen of the speculum. The trigone, which is more injected than 
the rest of the bladder, is the space between the two ureteral 
orifices and the opening of the urethra. It is small ; therefore, the 
ureteral orifice is near at hand. If a V is marked on the external 
upper part of the cylinder of the cystoscope, with its point toward 
the bladder end and the sides of the V separated by an angle of 
thirty degrees, the ureteral orifice on one side may be found by 
bringing an arm of the V parallel with the axis of the urethra, when 
the cystoscope will point toward the ureteral orifice on the same 
side. The ureteral opening is a little slit situated on the mons 
ureteris, a slight eminence. 



CATHETERIZATION OF THE URETERS 115 

Inspection of the urethra, endoscopy, is practised as the cysto- 
scope is withdrawn. The neck of the bladder is recognized as the 
first part of the rolling-in rim of mucous membrane coming into the 
lumen of the cystoscope as the latter is being withdrawn. Then in 
succession follow the different portions of the urethra, the meatus 
being last. After the patient has been restored to the dorsal 
position following cystoscopy in the knee-chest position, it is 
essential to pass the silver catheter into the bladder to let out the 
air which has accumulated. If the physician remembers to do 
this the patient will be spared the ardor urinaB and the discomfort 
which attend a distended bladder. Occasionally the endoscope 
of Skene or the urethral bivalve speculum recommended by him 
are of great service in viewing the interior of the urethra, especially 
in investigating new growths. These instruments have not been 
included in the list of instruments necessary for the investigation 
of the urethra, because the cystoscope generally answers every 
purpose of diagnosis, and simplicity of technique is aimed at in 
this book. 

Catheterization of the Ureters.— If the bladder is the seat of 
infective inflammation the physician should debate seriously the 
advisability of catheterizing the ureters, more especially if he has 
reason to believe that the ureters are not infected. If it is a 
question of unilateral gonococcus or tuberculous infection of kidney 
and ureter with enlarged kidney and thickened ureter, the diseased 
ureter should be catheterized, the healthy ureter should not be 
catheterized, because of the great danger of introducing septic 
matter into a sound ureter, the problem being similar to that of 
passing the catheter through the neck of the bladder in cases of 
gonorrhea of the urethra, or of introducing instruments beyond the 
internal os uteri in infections of the vagina and cervical canal. 
Nature has set up well-defined barriers against infection, and the 
physician should be assured of good results to follow before breaking 
them down. 

The ureteral orifices are found by depressing the handle of the 
cystoscope and carrying it to one side while the tip is raised toward 
the patient's sacrum. The dimensions of the trigone are borne in 
mind and the orifice shows in the proper place as a minute opening 
from which a drop of urine spurts every few moments. The 
rapidity of the flow of urine is dependent on the activity of the 



116 THE URETHRA, BLADDER, AND URETERS 

kidney, on the amount of fluids the patient has recently taken, 
and on the state of the nervous system. Sometimes it is advisable 
to regulate these factors before proceeding with a cystoscopy. Both 
orifices should be found before a catheter is passed, because in 
some cases the orifice may be displaced by uterine malpositions, by 
pelvic inflammation, or by other abnormalities of the pelvic organs. 

The ureteral orifice being found, the ureteral searcher is passed 
into it to make sure that it is the ureter and not a pocket in the 
mucous membrane. Then the catheter is passed and the cystoscope 
is withdrawn over it. The cystoscope with its obturator in place 
is reintroduced beside the catheter and the opposite ureteral orifice 
is found and catheterized in similar fashion. 

Now the patient is gradually lowered into the dorsal position, 
the physician guarding the ends of the catheters as she moves. 




Fig. 56. — Nitze's Model of Ureter Cystoscope for Catheterizing Both Ureters. 

The sterile two-ounce bottles collect the urine from each ureter, 
the amount of urine and the time of flow being noted on each bottle 
as well as the ureter from which the urine came. Great care is to 
be taken to mark the bottles correctly, and to this end it is best 
to stick a gummed label on each bottle before the catheterization, 
and to mark the bottles at once after they are used. 

In exceptional cases something may be learned as to stone in 
the ureter or stricture of the ureter by passing ureteral bougies. 
Wax-tipped bougies have been used with success in diagnosticating 
stone in the kidney, but much skill, gained by long experience in 
this field, is necessary to produce results. 

Catheterization of the ureters with the patient in the elevated- 
pelvis position, a more convenient position when an anesthetic 
is used, is conducted much as in the knee-chest position. The 
light is held close to the patient's pubcs and the operator stands 
looking downward, through the cystoscope to the trigone. When 



INDIRECT CYSTOSCOPY 



117 



the catheters are in place the patient's pelvis is lowered to 
the table. 

It should be remembered that the cystoscopic appearances and 
the situation of the ureteral orifices are altered 
by malpositions and tumors of the uterus and 
by other pelvic tumors. For instance, in pro- 
lapse folds appear in the bladder mucosa after 
reposition of the uterus and the cystocele. 

Indirect Cystoscopy with Water-Distended 
Bladder. — The instruments necessary are : — a 
Nitze cystoscope with wires and electric-light 
connection, a current controller and source of 
electricity, such as the street current or a 
storage battery, irrigating bag and one-per- 
cent boric-acid solution, urethral calibrator, 
urethral catheter, uterine applicator, absorb- 
ent cotton, and cocaine. The bladder should 
have a capacity of at least five ounces and 
the fluid should be clear; if it is not, an irrigat- 
ing cystoscope must be employed. The pa- 
tient is in the dorsal position; the meatus urin- 
arius is dilated with the urethral calibrator 
(cocaine being used if necessary as described 
in direct cystoscopy, page 110) until it will 
admit a No. 25 French sound, the usual diameter of most cysto- 
scopes. If there is a stricture of the urethra it must be dilated. 
No bleeding should accompany the introduction of the c}^stoscope, 
because it will spoil the view in the bladder. Before introducing 
the cystoscope fill the bladder with boric-acid solution and allow 
it to run out until the water is clear, then from five to seven 
ounces are injected and the catheter withdrawn. The cystoscope 
is connected with the source of light and the lamp tested. Then 
the current is turned off and the instrument is smeared with 
lubrichondrin and introduced, care being taken to depress the 
handle as the curve passes the neck of the bladder. 

The following are the appearances of the bladder as seen through 
the cystoscope according to Casper ("A Text-Book of Genito- 
urinary Diseases "), The normal mucous membrane of the bladder 
varies from light yellow to pink, being redder at the base than in 




Fig. 57. — Current 
Controller for Use with 
Electric Cystoscope. 




118 THE URETHRA, BLADDER, AND URETERS 

other parts. In the course of a prolonged examination urine is 
poured out into the bladder by the ureters and the color of the 
mucosa becomes redder because of the yellowness of the medium 
through which it is seen, also if the brightness of the light dimin- 
ishes the color becomes redder, therefore the light should be bright 

and white. The delicate ramifying 
blood-vessels, especially well marked 
at the fundus, are similar to the 
vessels seen with the ophthalmoscope 
at the fundus of the eye. Bundles of 
muscle fibers, parts of the detrusor 
vesica?, make little ridges in the blad- 
der walls, especially in the superior 
and lateral portions. Exaggerations 
Practising Cystoscopy. of these ridges become the "trabec- 

ule" in the cases of hypertrophy of 
these muscles when increased work has been thrown upon 
them, as in stricture of the urethra. Between the trabecule 
may be diverticula, which look like deep excavations in the bladder 
wall. A shadow will cover a part of the circular field of vision if 
the cystoscope is withdrawn from the middle of the bladder. This 
is due to the fact that a part of the prism in the cystoscope is 
covered by the sphincter vesica? muscle. Carrying the beak of 
the instrument downward brings the base of the bladder into view, 
and pushing it a little backward and to one side brings the opposite 
ureteral elevation into the field. If the ureteral eminence is 
watched for a little time it will be seen to swell up suddenly, make 
a convulsive movement, and at the same time an eddy will be 
observed in the bladder fluid. This is the periodic discharge of 
urine. If the urine is discolored the bladder fluid will have to be 
renewed either by irrigation through a catheter or an irrigating 
cystoscope. Often the urine from one ureter will be clear and from 
the other cloudy. 

This form of cystoscopy, like the direct form, should not be used 
in the presence of acute inflammation of the bladder and it can 
not be employed in the case of a contracted bladder. In chronic 
catarrhal cystitis the mucous membrane appears to be puffy, 
velvety, and red, and is coated with secretion. The vascular 
network is no longer visible, the surface of the bladder looking 



CHROMOCYSTOSCOPY 1 1 9 

cloudy and dull. Scales and flakes of secretion are found floating 
free in the fluid or on the bladder wall. Tuberculous cystitis 
shows nodules surrounded by a reel border situated mostly on the 
floor of the bladder, and in advanced cases distinct ulcers are 
visible. Tumors of the bladder give especially good pictures with 
this form of cystoscope and so do vesical calculi. Foreign bodies 
can be distinguished and their size and shape determined, and a 
ureteral catheter, introduced into a ureter, may be seen disappear- 
ing through the ureteral orifice and throwing a shadow below it on 
the base of the bladder. 

To those who are interested in this form of cystoscopy the 
following books are recommended : " Die Cystoskopie beim Weibe," 
Dr. Richard Knorr; "Handbuch der Cystoskopie/' Dr. Leopold 



Fig. 59. — Luys Urine Separator. It Divides the Bladder into Halves by 
a Removable Diaphragm and the Urine from Each Half is Collected by a 
Separate Tube. 

Casper; "Handatlas der Cystoskopie," Dr. Otto Kneise; " A Hand- 
book of Clinical Cystoscopy," E. Hurry Fen wick. 

Chromocystoscopy. — Chromocystoscopy is a method of investigat- 
ing the functional capacity of each kidney that has been used 
abroad for the past six years with success. It consists of cysto- 
scopy with water-filled bladder. Fifteen minims of a five-per-cent 
aqueous solution of methylene blue are injected into the buttock. 
In five minutes, more or less in individual cases, the urine is rendered 
blue and can be seen through the cystoscope spurting from the 
mouths of the ureters. The urine from the two ureters is com- 
pared as regards the following points: — The interval before its 
appearance, the intensity of the color, the number of jets to the 
minute, and the force of the jet. If one ureter eliminates dark 
blue urine while there is no trace of stain in the urine from the other 



120 THE URETHRA, BLADDER, AND URETERS 

kidney, there may be obstruction by a stone in the ureter giving 
colorless urine, or compression of this ureter so that the passage of 
the urine is delayed, or such extensive destruction of the kidney 
tissue on this side that the stain has not been excreted. The 
method is said to obviate the necessity for ureteral catheterization 
in many cases and to give a reliable indication of the functional 
capacity of each kidney, besides affording a means of finding an 
otherwise hidden ureteral orifice. 



CHAPTER IX 

THE INVESTIGATION OF THE RECTUM 

Inspection of the anus, p. 121. Anatomy of the rectum, p. 121. Digital 
examination, p. 123. Proctoscopy, p. 124. Stretching the sphincter and 
speculum examination of the rectum with an anesthetic, p. 126. 

The frequent association of rectal and gynecological affections 
makes the diagnosis of the former important, also symptoms in 
gynecological disease are so often referred to the rectum that it 
becomes most necessary to eliminate rectal disease. 

Of course the rectum should be empty before an examination 
is made, an enema being given if there is any doubt on this point, 
and it should be given always in cases where the rectum is to be 
investigated with the proctoscope. In those cases in which there 
is protrusion of the bowel only at stool, the patient should go to 
the closet before the examination. 

Inspection of the Anus. — The best position for both visual and 
digital examination is the Sims position. Inspection of the anus 
may show external hemorrhoids, and internal hemorrhoids after 
the patient has just been to the closet, external fistulae, ulcerations, 
pin worms, abscess, fissure, and skin diseases, such as eczema and 
venereal warts. If the buttocks are separated by the hands and 
the patient bears down, a fissure may be brought into view. 

Some points in the diagnosis have been obtained already from the 
vaginal examination. Tumors can be ruled out by the vaginal 
touch. The sphincter ani is now everted by a finger in the vagina 
pressing the rectal wall out through the anus, thus affording an 
opportunity for study and a search for hemorrhoids, polypi, ulcera- 
tions, fissures, or fistula?. This procedure can not, however, be 
executed in virgins with unstretched perinea, a reasonable amount 
of injury or elasticity of the perineum being a necessity. 

Before taking up the digital examination let us review a few points 
in the anatomy and physiology of the rectum. 

Anatomy of the Rectum. — The rectum is about eight inches long, 
merging above into the sigmoid flexure of the descending colon at 

121 



122 THE INVESTIGATION OF THE RECTUM 

the left sacro-iliac articulation, there being no distinct point of sepa- 
ration between the two. The upper portion, four inches long, is 
almost completely surrounded by peritoneum. The peritoneum 
is reflected from the anterior surface of the middle portion or 
ampulla, which is three inches long, at a point about two 
and a quarter inches from the anus to pass on to the posterior 
wall of the vagina. As the anterior and posterior walls of this 
part of the rectum are in apposition when it is not distended 
by feces or gases, it appears in sections as a transverse slit. 
The third portion, or anal canal, an inch long, is the part 
surrounded by the internal sphincter above and external 
sphincter below, and supported by the le vat ores ani muscles. 
When empty this part is seen in a vertical median section as a 
longitudinal slit. It is to be borne in mind that the long axis of 
the canal of the anus is nearly horizontal when the patient is in the 
erect posture and is at approximately a right angle to the long axis 
of the two upper portions of the rectum, — therefore the anus dis- 
charges the fluid fecal contents not downward in the axis of the 
body, but backward. The soiled state of the rear boards of a coun- 
try privy bears testimony to this fact in anatomy. When solid 
fecal masses are passed the anal canal is taken up much as the cervix 
uteri is taken up during labor, and the feces are extruded down- 
ward. This obliquity of the anal canal to the main lumen of the 
rectum lessens the direct strain on the sphincter made by accu- 
mulations of fecal matter and gases. 

The rectum is composed of four coats, — serous, muscular, areolar, 
and mucous. It is similar in structure to the rest of the large in- 
testine, except that the semilunar folds of the mucous membrane 
to be found higher up in the bowel are here strongly developed, so 
that they form shelves projecting into the lumen of the gut. These 
shelves or valves (valves of Houston) are generally three in number, 
two high up, are on the sides of the rectum, a third and the largest, 
is in front opposite the base of the bladder. When a fourth is 
present it is in the ampulla on the posterior wall about an inch 
above the anus. These valves are disposed alternately. When 
the rectum is empty they overlap each other so that it is difficult to 
pass a bougie or other foreign body by them. Their function is 
probably to support the weight of fecal matter and prevent it from 
impinging on the anus where its presence is sure to excite a desire 



DIGITAL EXAMINATION 123 

for defecation. Just above the internal sphincter the mucous 
membrane is thrown into three or four longitudinal folds on each 
side. These are known as the columns of Morgagni. Between 
them are little pockets, or valves. 

The vessels of the rectum lie in the loose areolar tissue between 
the muscular and mucous coats, and, receiving no support from the 
muscles, varicosity is favored. Moreover, the veins pierce the 
muscular coat, run superficially in a longitudinal direction, and 
are apt to be constricted when the muscle contracts; also there are 
no valves in the superior hemorrhoidal veins, and hardened feces 
are likely to press on them and stroke the blood downward, away 
from the heart. The mucous membrane is thick and loosely con- 
nected to the muscular coat beneath, thus favoring prolapse, 




Fig. 60. — Short Proctoscope. 

especially in the child, where the rectum is straight er than in the 
adult. 

The reflex contractions of the sphincter prevent healing of a 
fissure and are a source of pain. They also prevent an ischio-rectal 
abscess from closing and convert it into a fistula. Because over- 
developed by its activity in such cases, the sphincter is especially 
strong; therefore it must be thoroughly stretched to the point of 
temporary paralysis before any operative procedure can be under- 
taken with the hope of a successful outcome. 

Digital Examination. — The well-anointed left forefinger is passed 
into the anus, the direction being first forward toward the vagina 
and then backward. If the patient bears down as the tip of the 
finger passes through the anus, the sphincter is relaxed and the 
anal canal is straightened. Thus the discomfort is lessened while 
the finger is introduced gradually with a boring motion. The an- 



124 THE INVESTIGATION OF THE RECTUM 

terior and side-walls of the ampulla are palpated. A lesion on the 
anterior wall is felt between the left forefinger in the rectum and 
the right forefinger in the vagina. The strength of the sphincter 
ani is estimated, spasm, due to long-continued irritation, areas of 
induration, ulceration, or narrowing of the caliber of the gut, and 
the presence of tumors are determined. A general smoothness and 
absence of folds indicates atony. 

The right forefinger, in like manner, is used to palpate the 
posterior wall of the ampulla. The presence of internal piles is 
very hard to diagnosticate by touch. The proctoscope must be 
used for these. In making the digital examination it is well to 
pass the unused fingers of the examining hand between the nates, 
or over the vulva and the thumb beside the vulva or between the 




Fig. 61. — Long Proctoscope. 

nates, for in this way a greater distance can be reached in the 
rectum than by shutting the unused fingers on the palm of the 
hand. If, after the digital examination, the diagnosis is still in 
doubt, the Kelly proctoscope should be used. 

Proctoscopy. — A good light, preferably an electric light and 
a head mirror, are necessary, just as in cystoscopy. The patient is 
put in the knee-chest position. Something as to the condition of 
the anal canal may be learned by the use of the smallest-size Sims 
vaginal speculum in the anus and some physicians report good 
results with it. Personally, I have not found it valuable as a 
means of diagnosis unless the sphincter has been first stretched. 
The Sims rectal speculum is adapted only for use with the patient 
anesthetized. 

Two proctoscopes are sufficient for diagnostic purposes. The 
shorter one, three inches (7.5 centimeters) long by seven-eighths 



PROCTOSCOPY 125 

inch (2.3 centimeters) in diameter, is passed first. It is thoroughly 
anointed and introduced slowly while the patient bears down. 
The physician keeps in mind the direction of the anal canal and the 
rectum proper; the tip of the proctoscope with its obturator in 
place is pointed first downward toward the pubes, then inward in 
the axis of the body after the sphincter has been passed, and then 
upward toward the sacrum. Remember the situation of the 
valves of the rectum and work the tip of the proctoscope by them 
gradually. Removing the obturator air rushes in, balloons the 
rectum, and permits a view of the lower part of this organ. The 
alligator forceps are useful to remove bits of fecal matter or to 
wipe away secretion with cotton pledgets, or to obtain tissue for 
microscopic examination. As the proctoscope is withdrawn the 
internal and external sphincters are inspected as they roll into the 
lumen of the proctoscope. The longer proctoscope, five and a 




Fig. 62. — Long Alligator Forceps. 

half inches (14 centimeters) long by seven-eighths inch (2.3 centi- 
meters) in diameter, is of value to inspect the upper rectum. The 
sigmoidoscope is a dangerous instrument, for although by its use, 
in. favorable cases, a glimpse of the sigmoid may be obtained, it 
is likely to injure the bowel. 

In introducing the longer proctoscope it is advisable to remove 
the obturator after the sphincter has been passed and to carry the 
instrument higher in the rectum by sight. The semilunar valves 
can be seen and avoided by the advancing edge of the proctoscope. 
Remember that the empty rectum is normally contracted — that 
is to say, its walls are in apposition — therefore this state must 
not be mistaken for stricture. The air sometimes does not separate 
the walls of the upper rectum, although it does those 1 of the ampulla. 

The mucous membrane of the rectum is studded by branching 
vessels and the openings of little glands may be seen. Inflamma- 
tion is marked by a diffuse velvety injected appearance of the 



126 



THE INVESTIGATION OF THE RECTUM 



mucosa, together with the disappearance of the normal branching 
vessels; ulcerations are easily distinguished, polypi may be seen 
hanging from the rectal wall, or the bleeding surface of a carcinoma 
may obstruct the lumen of the proctoscope. If there is stricture 
of the bowel because of syphilis, or cancer, a smaller proctoscope 
should be used. A large-sized Kelly cystoscope will often serve 
instead of a proctoscope in such cases, also in the examination of 
the rectum in children. 

Stretching the Sphincter and Speculum Examination of the Rectum. 
In exceptional cases it is necessary to give an anesthetic in order 
to make a complete diagnosis of rectal disease. In such an event, 
after the patient is thoroughly anesthetized she is placed in the 




Fig. 63. — Sims Rectal Speculum. 

Sims position ; the operator anoints both thumbs and inserts them 
through the anus. By means of the fingers grasping both buttocks 
gentle but firm traction is made on the sphincter ani. A good deal 
of time should be devoted to the stretching of the sphincter, some 
fifteen minutes. Rapid and forcible stretching is very apt to 
result in rupture of the muscle followed by partial or complete 
permanent incontinence of feces or in fissure of the mucous 
membrane. Thorough stretching of the sphincter is an essential 
for any instrumentation of the rectum except proctoscopy. After 
the preliminary stretching the sphincter muscle is fixed between the 
thumb and forefinger of the left hand and successive portions of 
its periphery are stretched by the thumb and forefinger of the right 
hand. The Sims rectal speculum is passed and light is reflected 
into the rectum by the head mirror, the alligator forceps and pled- 
gets of cotton being used to wipe away discharges and feces. 



CHAPTER X. 

THE SIGNIFICANCE OF THE CHIEF SYMPTOMS OF 
PELVIC DISEASE. 

Dysmenorrhea, p. 128: Frequency, p. 128; Menstrual niolimena, p. 
128. I. Dysmenorrhea associated with pelvic lesions, p. 129: Congenital 
malformations, Retroposition with anteflexion, Pelvic inflammation, Fibroids, 
p. 129. II. Dysmenorrhea where no pelvic lesion can be found, p. 130: 
Neurotic dysmenorrhea, Dysmenorrhea due to poor general health, p. 130. 
Membranous dysmenorrhea, p. 130. 

Intermenstrual pain, p. 132: Description, p. 132. Etiology, p. 133. 

Menorrhagia and Metrorrhagia, p. 134: I. Constitutional causes, p. 135. 
II. Local causes, p. 135: 1. The patient is a virgin, p. 136; Table of men- 
orrhagia and metrorrhagia in virgins, p. 137; 2. The patient is not a virgin 
and (a) has never been pregnant, p. 137, (6) has been pregnant, p. 138; (c) is 
pregnant, p. 138; Table of monorrhagia and metrorrhagia in married women, 
p. 139. 

Amenorrhea, p. 139: 1. Primary amenorrhea, p. 139: Due to (a) Failure 
of growth, p. 139; (b) Atresia of the hymen or of the vagina, p. 140. 2. 
Secondary amenorrhea, p. 141: Due to (a) Pregnancy and lactation, p. 141; 
(b) Atrophy of the ovaries, p. 141; (c) Constitutional diseases, p. 141; (d) 
Exhaustion and shock, p. 142; (e) Retention of menses from acquired atresia 
of the genital canal, p. 142. 

Leucorrhea, p. 143: Character of the discharge, p. 143: White dis- 
charge, p. 143; Yellow discharge, p. 143; Watery discharge, p. 144; Fetid 
discharge, p. 144; Bloody discharge, p. 144. Occurrence of leucorrhea, p. 
144: Leucorrhea in children, p. 144; Leucorrhea in virgins, p. 145; Leu- 
corrhea in married women, p. 145; Leucorrhea in old women, p. 146. 

Dyspareunia, p. 146: 1. Psychical causes, p. 146. 2. Anatomical 
causes, p. 146. 

Sterility, p. 147: Absolute, p, 147; Secondary, p. 147; Facultative, p, 
147. Sterility in the male, p. 148. Sterility in women, p. 148: Age as a 
factor, p. 148; Other factors, p. 149, Anomalies and diseases of the uterine 
organs, p. 150; Conditions of the uterine organs that cause interruption of 
pregnancy, p. 150, Constitutional diseases and general causes, p. 151. 

Vesical symptoms, p. 151 : 1. Dysuria, p. 151; General causes and local 
causes, p. 152. 2. Too frequent urination, p. 153. 3. Incontinence of 
urine, Enuresis, p. 154: Local causes, p. 154; General causes, p. 155; 
Nocturnal enuresis, p. 155. 4. Retention of urine, Ischuria, p. 155. 5. 
Suppression of urine, Anuria, p. 156. 

Rectal symptoms, p. 156: Pain, p. 156. Hemorrhage, p. 157. Rectal 
discharge, p. 157. Fecal accumulation, p. 157. Difficulty in defecation, p. 
158. Protrusion from the anus, p. 158. Character of the feces, p. 158. 

127 



128 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

Coccygodynia, p. 159: Etiology and pathology, p. 159. Symptoms, p. 
159. Diagnosis, p. 160. 

Pruritus vulvae, p. 160. Caused by: 1. Irritating discharges from the 
vagina or bladder, p. 160; 2. Diseases of the vulva, p. 161; 3. Neuroses, 
p. 161. 



DYSMENORRHEA 

The term dysmenorrhea (from &>?, difficult, fiyv, month, and 
fiieiv } to flow) signifies painful menstruation, and is used to 
define suffering of whatever kind associated with the performance 
of the function of menstruation. In spite of the many theories 
advanced to explain the occurrence of pain accompanying, preced- 
ing, or following the monthly flow, we are still ignorant of the cause. 
Authorities are not agreed as to the frequency of pain among 
normal women. Theoretically the woman should be conscious of 
menstruation only by the discharge of blood from the vulva; as 
a matter of fact a considerable proportion of women have some sort 
of discomfort. Marie Tobler (Monatsschr. fur Geburts. und Gyn., 
1905, Vol. XXII., p. 1) investigated this question in the case of 
one thousand and twenty women and found that twenty-six per 
cent had local pain, general discomfort, malaise, weakness, or 
mental disturbance at menstruation. Some writers place the 
percentage of local or general discomfort as high as sixty or seventy 
per cent of all women. It is to be remembered, however, that 
most of the data come from investigators who have to do with 
women afflicted with uterine disease and not with normal women. 

Menstrual molimina are the local and general disturbances that 
are supposed to be normal to menstruation; they are: — a certain 
amount of pain in the pelvis extending through the back and thighs, 
also nervous depression, resulting in lassitude, headache, nervous 
instability, and derangement of the function of different organs. 

Some of the last are: eye strain, skin eruptions — such as urticaria 
and acne, — pains in the joints, and loosening of the sacro-iliac 
joint in the case of sacro-iliac disease, and various sorts of " neu- 
ralgias." They are often spoken of as "reflex symptoms." Ex- 
aggeration of the menstrual molimina constitutes dysmenorrhea, 
although the term is more often applied to the actual pain which 
is referred to the pelvis than to the more distant manifestations. 

Dysmenorrhea may be classified as of two sorts, (1) that associ- 



DYSMENORRHEA 129 

ated with definite discoverable lesions of the uterine organs, and 
(2) that in which no abnormality of those organs can be deter- 
mined. 



1. Dysmenorrhea Associated with Pelvic Lesioxs 

This includes dysmenorrhea occurring in the case of (1) Con- 
genital malformations of the uterine organs, (2) retroposition with 
anteflexion, (3) pelvic inflammation, and (4) fibroids. 

i. Congenital Malformation of the Uterine Organs. — A woman 
having an infantile uterus or a congenitally anteflexed uterus is 
apt to suffer with dysmenorrhea, so also, in the case of atresia of 
the vagina or of the uterus where the ovaries are at the same time 
well developed, pain recurring at regular intervals is apt to be a 
constant symptom. 

2. Retroposition with Anteflexion. — Dysmenorrhea is the rule with 
this affection, especially in the case of the unfruitful. The pain 
in these cases generally begins with the appearance of the flow, it 
is cramp-like, and is relieved after the flow has become well estab- 
lished. Frequent and painful micturition is often associated with 
this malposition, whatever the cause may be. 

This is a sort of uterus in which the so-called obstructive dysmen- 
orrhea was supposed by Marion Sims and his followers to occur. 
This theory is that the escape of the menstrual discharges is impeded 
by the flexing of the uterine canal by a stenosis either of the internal 
or the external os, by an intra-uterine polyp acting like a ball- 
valve, or by clots of blood. At the present time the best authori- 
ties are agreed that actual obstruction seldom exists. 

3. Pelvic Inflammation. — Pelvic inflammation includes endome- 
tritis, and also pelvic peritonitis, salpingitis, ovaritis, and a certain 
amount of cellulitis. In the acute stages of pelvic inflammation 
dysmenorrhea is a fairly common symptom — perhaps in from a 
third to a half of all cases. In the chronic stages it causes uterine 
malposition and chronic endometritis, which are more directly 
causative of painful menstruation. The pain is apt to antedate 
the beginning of the flow and lasts through the entire period. 

4. Fibroids. — Dysmenorrhea is a fairly constant accompaniment 
of submucous and interstitial myomata. It is rare in the sub- 
peritoneal sort. The size of the tumor bears no definite relation 

9 



130 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

to the amount of the pain experienced; often the pain is most 
severe in the case of very small tumors. The pain in the uterus 
itself must be differentiated from the more or less constant pain 
due to pressure by large tumors on the surrounding nerves in the 
pelvis. The pain in the uterus, according to Kelly and Cullen 
("Myomata of the Uterus"), is most severe at, or just before, the 
menstrual period. The pain from pressure is apt to be in the legs 
and feet and may be mistaken for rheumatism. 



II. Dysmenorrhea Where no Pelvic Lesion Can be 

Found 

Dysmenorrhea often exists in women who, apparently, have 
perfectly normal uterine organs. In this event the painful men- 
struation is (1) neurotic, or (2) due to poor general health. 

i. Neurotic Dysmenorrhea. — Neurotic dysmenorrhea appears to 
be due to excessive sensitiveness of the endometrium. The uterine 
contractions occurring during menstruation cause abnormal pain, 
something like the after-pains of labor. The formation of clots in 
the uterine cavity, exciting expulsive contractions and pain, has 
been assumed to be the cause in some cases, but there are no facts 
to substantiate this theory. Dysmenorrhea is often observed in 
cases of neurasthenia and sometimes in patients with this disease 
who previously had not had painful menses. The physician is 
often left in doubt which is cause and which effect in the investiga- 
tion of neurasthenia and dysmenorrhea. 

2. Dysmenorrhea Due to Poor General Health. — Dysmenorrhea is 
observed frequently in girls under twenty who are the subjects of 
anemia or chlorosis. There are no satisfactory theories among the 
many that have been advanced to explain this association of men- 
strual suffering with these two diseases. 

Membranous Dysmenorrhea. — Membranous dysmenorrhea is 
characterized by severe cramp-like pains in the lower abdomen 
and back, resembling labor pains, occurring at the time of men- 
struation and followed by the expulsion of a more or less incomplete 
cast of the cavity of the corpus uteri in the shape of a sac, triangular 
in form, gray in color, and having a rough surface. When floated 



MEMBRANOUS DYSMENORRHEA 131 

in water and laid open, the interior of the sac is smooth. With 
the aid of a magnifying glass this smooth surface is seen to be 
studded with minute openings which represent the mouths of the 
utricular glands. If the sac is reasonably complete — it is seldom 
entire — the openings of the Fallopian tubes may be distinguished 
in the upper corners. The membrane is from one to three milli- 
meters thick and under the microscope shows much the appear- 
ance of exudative interstitial endometritis, although the patho- 
logical characteristics of the membrane are not constant; therefore 
membranous dysmenorrhea is not a definite disease but a condition 
which exists in the presence of different pathological processes. 

The etiology of this disease is shrouded in mystery. As far as 
known, endometritis precedes membranous dysmenorrhea in a 
large proportion of cases. In certain cases menstruation is normal 
and regular until infection occurs following abortion or labor; then 
membranous dysmenorrhea develops in the course of a few months. 
In another class of cases, many of them being unmarried women, 
menstruation is normal and regular and the painful menstruation 
with the expulsion of a membrane develops without any apparent 
cause. Following the expulsion of the membrane there is generally 
a profuse flow of blood. 

In making a diagnosis of membranous dysmenorrhea we must 
exclude (a) decidual endometritis and (b) exfoliative vaginitis. 

(a) In the case of decidual endometritis there is a history of 
pregnancy, also some of the signs of pregnancy or extra-uterine 
pregnancy should be present (see Chapters XXII and XIX). 
Hemorrhage following the expulsion of the membrane, or parts of 
it, generally lasts longer and is more profuse than is the case with 
membranous dysmenorrhea. The cast of the uterine cavity is 
larger and more vascular than in the case of the membrane of dys- 
menorrhea, and chorionic villi should be visible when the specimen 
is examined under the miscroscope. 

(b) Exfoliative vaginitis may accompany membranous dysmen- 
orrhea, the exfoliation of the vagina being a part, apparently, of 
the same pathological process which causes the casting off of the 
endometrium. Such an association, although authoritatively 
reported, must be considered as very rare. Exfoliative vaginitis 
occurring as a result of inflammation or from treating the vagina 
with strong caustics, such as nitrate of silver (see Chapter XX, page 



132 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

364), is a not uncommon disease, and if the lining mucosa is thrown 
off at the time of a menstruation which is accompanied by cramps, 
the physician must be able to distinguish between a cast from the 
vagina and one from the uterine cavity. 

A vaginal cast when floated in water does not present a tri- 
angular shape and no tubal openings are to be seen. However, as 
all casts are often expelled in pieces, these features may be absent 
in both cases. On examining a vaginal cast with a magnifying 
glass it will be seen to have a surface that is relatively rough and 
there are no openings of glands in it. Microscopic examination 
shows it to be made up of stratified vaginal epithelium and the 
characteristic glandular structure of the endometrium is absent. 



INTERMENSTRUAL PAIN 

Intermenstrual pain, or "Mittelschmerz," is the name given to 
pain similar to the pain of dysmenorrhea, occurring on a definite 
date between two menstrual periods, often midway between, but 
not always. 

This affection is by no means uncommon and every gynecologist 
of wide experience has met with several cases. Dr. H. A. Kelly 
(" Medical Gynecology ") has collected sixty-four cases from his own 
experience and the literature, and I will summarize his conclusions 
from an analysis of these cases. 

As a rule intermenstrual pain does not begin with the first 
menstruation, but is generally noted during the period of full sexual 
activity, that is, between the years of twenty and thirty-five. In 
a majority of cases it is associated with sterility, but in a large 
proportion of the child-bearing women who are the subjects of this 
pain, pregnancy seems to stand in a causal relation to the inter- 
menstrual pain. 

Three cases of intermenstrual pain have been reported in which, 
pregnancy supervening, the pain ceased entirely during pregnancy 
and during lactation, only to return on the re establishment of 
menstruation. 

The pain always occurs about the middle of the intermenstrual 
period and extends into the second half of it, and the date of the 
intermenstrual pain seems to depend on the date of the beginning 



INTERMENSTRUAL PAIN 133 

of the following menstrual period and not on that of the preceding 
period. 

Exact data as to the beginning of regular menstruation and the 
beginning of the intermenstrual pain should be made in every case 
for record. The character of the pain varies in individual cases, 
it may be dull or it may be sharp; it is seldom paroxysmal. It is 
situated in the pelvic region, just as in dysmenorrhea. The pain 
lasts from a few da} 7 s, up to the entire time from its beginning imtil 
the next menstruation. It generally lasts three or four days. 

Intermenstrual pain may be present during all of a woman's 
menstrual life. We have no assurance that it will cease short of 
the menopause. It does not seem to be associated with dysmenor- 
rhea, although precise information on this point is lacking, as it is 
on the question of its association with regularity and irregularity 
of menstruation. There is a very great probability that many cases 
rated as irregularity of painful menstruation would, if analyzed 
carefully, be found to be cases of intermenstrual pain. 

In a majority of cases of intermenstrual pain the suffering is 
accompanied by a vaginal discharge, either as a watery leucorrhea, 
or a yellowish or blood-stained discharge. Often, a uterine lesion, 
such as endometritis, a polyp, or a submucous fibroid will be found 
to explain the leucorrhea. As a rule, no definite relation has been 
established between pelvic lesions and intermenstrual pain. 

As regards the causation of this affection, Kelly is inclined to 
agree with Sir William Priestly, who first reported four cases of the 
disorder in 1871 (Brit. Med. Jour., Vol. II., p. 683). His theory 
is that under normal conditions previous to menstruation, one or 
both ovaries become congested, the congestion persisting through 
menstruation and for a few days after. This congestion is attended 
by no signs. Under abnormal conditions, because of changes 
in the ovaries not understood, the congestion begins earlier 
than usual and is attended by pelvic pain. Therefore the pain 
has relation to the coming period and not to that which has 
preceded the pain. In the cases observed clinically such a relation 
is found to exist. 

Plrysicians are urged to report cases of intermenstrual pain with 
exactness so that data may be in hand as to this interesting and 
neglected affection. Besides the patient's age and social condition, 
the following points should be noted: — (1) Day of the month on 



134 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

which the last menstruation began. (2) Date at which intermen- 
strual pain began. (3) Date at which the following catamenia 
began. (4) Length of time the pain lasts, and its character. (5) 
Date when intermenstrual pain was first noted. (6) Full details 
of a normal menstruation, i.e., exact interval between beginning of 
each two catamenia, duration of the flow in days, amount of flow 
in napkins each day, occurrence of pain and leucorrhea. (7) 
Whether or not intermenstrual pain is attended by a vaginal dis- 
charge, and if so, its amount and character. (8) If a pelvic exam- 
ination has been made, note the findings. 



MENORRHAGIA AND METRORRHAGIA 

Menorrhagia (monthly bleeding, from nve? } menses, and 
pjj-jrvuvaij to burst forth) an excessive loss of blood at the men- 
strual periods, and metrorrhagia (uterine bleeding, from ^rpa } 
womb, and fayvuvatj to burst forth) a loss of blood independent 
of menstruation, are two terms which frequently can not be used 
with discrimination because the two conditions so often coexist. 
That is to say, a metrorrhagia becomes a menorrhagia when the 
menstrual period arrives, and menorrhagia, as in the case of a 
submucous fibroid, in the course of time becomes a metrorrhagia. 
Therefore it will be convenient to consider the two symptoms 
together, bearing in mind the fact that menorrhagia may be due 
to constitutional disease, whereas metrorrhagia is always due to 
disease of the pelvic organs. Menorrhagia is a relative term, for 
what is a moderate flow for one woman would be rated as excessive 
by another. Therefore, before pronouncing that menorrhagia 
exists in any given case, the physician must inquire minutely as to 
the patient's normal habit of menstruation, getting the number of 
days that the flow lasts, and the number and size of the napkins 
used, and whether they are well saturated or not. As a rule, 
under normal conditions, most of the flow occurs during the first 
two or three clays. Find out whether this is the case. Supposing 
that it is, a loss of blood of a like amount, lasting through five or 
six days, would constitute menorrhagia. If the flow is increased 
during the normal menstrual time it is one type of menorrhagia, 
and a menstruation unduly prolonged in point of time is another. 



MENORRHAGIA AND METRORRHAGIA 135 

Only painstaking questioning, or the results of observation by a 
nurse, will establish the facts. 

In investigating a case of menorrhagia the constitutional causes 
should be considered first, then the local causes. Only the habit 
of excessive menstruation — not for one or two periods only — should 
necessitate a diagnosis, and, particularly in the case of unmarried 
girls and women, constitutional diseases must be eliminated care- 
fully before proceeding to local examination. The establishment of 
menstruation at puberty is frequently attended by menorrhagia 
for several periods. Family tendencies are to be borne in mind. 
In some families it is the habit for the women to flow freely, and in 
others the reverse holds true. 



I. Constitutional Causes of Menorrhagia 

The following blood conditions are known to be attended by 
menorrhagia: — hemophilia, purpura, scurvy, leukemia, the uremia 
of nephritis, and severe cholemia or jaundice. The various in- 
fectious diseases, such as small-pox, scarlet fever, cholera, typhoid 
fever, influenza, and malarial fever, often have excessive menstrua- 
tion as a symptom. Menorrhagia is not uncommon in the early 
stages of pulmonary phthisis, although amenorrhea is the rule in 
this disease. It also occurs in syphilis and in the chronic poison- 
ings of alcohol, lead, or phosphorus, and in organic heart disease 
and in cirrhosis of the liver. An excessive menstrual flow is apt 
to attend the initial stages of any acute constitutional disease. 
Heart disease favors climacteric hemorrhage, — a feeble or an in- 
sufficient heart making for pelvic congestion with consequent 
menorrhagia or metrorrhagia. 



II. Local Causes of Menorrhagia and Metrorrhagia 

Having ruled out the constitutional causes of menorrhagia, the 
physician should make a careful vaginal examination in all cases of 
persistent uterine hemorrhage, whether occurring at the menstrual 
periods or not. 

The local causes may be enumerated as follows: — 

Uterine congestion. 



136 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

Endometritis. 

Polypi. 

Abortion. 

Extra-uterine pregnancy. 

Subinvolution of the uterus. 

Submucous fibroids. 

Cancer of the cervix. 

Cancer of the fundus. 

Sarcoma. 

Chorio-epithelioma. 

Inversion of the uterus. 

Backward displacements of the uterus. 

Inflammation of the tubes and ovaries. 

Small cystic degeneration of the ovaries. 

Ovarian cyst with twisted pedicle. 

Arterio-sclerosis of the uterine blood-vessels. 

Vaginitis and injuries of the vulva and vagina. 

It may be well here to point out the probable diagnosis to be 
obtained from the patient's age, whether or not she is a virgin, or 
whether or not she has ever been pregnant. 

The following affections are common to the virgin, the married 
woman, and the multipara: — ovarian tumors, fibroids, and cancer 
and sarcoma. 

Arterio-sclerosis of the small blood-vessels of the uterus has been 
described by Henri Arnal, Palmer Findley, and others. It is 
essentially a disease of the senile uterus, although cases have been 
reported in the uteri of women between thirty and fort}' years of 
age. As yet we do not know how often this condition, which seems 
to be not very uncommon, is the cause of hemorrhage. 

1. The patient is a virgin, and (a) is under the age of twenty-five. 
Increase in the amount of menstrual flow is most often due to uterine 
congestion, perhaps brought on by exposure, or over-exertion dur- 
ing a menstrual period, or it may be due to a glandular polyp. In 
the latter case, the polyp generally produces metrorrhagia as well 
as menorrhagia, and thus we may distinguish between hemorrhage 
due to congestion and that due to a polyp. Uterine congestion is 
the direct cause of all uterine hemorrhage, the more remote causes, 
such as displacements and inflammation of the tubes and ovaries, 



MENORRHAGIA AND METRORRHAGIA 



137 



being many. Chronic endometritis, formerly thought to be the 
common cause of uterine bleeding, is now regarded as relatively 
rare, with the exception of the polypoid and the hyperplastic varie- 
ties. 

(b) Menorrhagia may be due to backward displacement of the 
uterus at any age before the menopause. From twenty-five to 
thirty-five uterine fibroids of submucous evolution are an important 
cause of both menorrhagia and metrorrhagia. Cancer, especially 
cancer of the fundus, is to be thought of as a cause of metrorrhagia 
after the age of thirty-five. A watery vaginal discharge accom- 
panies the flow very often in the case of cancer of the fundus; some- 
times also in fibroids. 

The facts may be summarized in the following table: — 



MENORRHAGIA AND METRORRHAGIA IN VIRGINS. 



Age. 



Under twenty-fin 



Menorrhagia. 

[ Uterine congestion. 
X Backward displacements. \ 
[_ Constitutional diseases. 



Metrorrhagia. 

Uterine polyp. 

Rarely, submucous fibroid. 



Twenty-five to 
forty. 



f Uterine congestion. 
j Endometritis. 



| Backward displacements. 
^Submucous fibroid. 



f Uterine polyp. 

Submucous fibroid. 

Rarely, cancer or sarcoma of 
[^ the body of the uterus. 



Over forty. 



Submucous fibroid. 
Endometritis. 
Uterine congestion. 
Backward displacements. 



[ Submucous fibroid. 
I Uterine polyp. 
•\ Cancer or sarcoma of 

body of the uterus. 
^Rarely, cancer of the cervix. 



the 



2. The patient is not a virgin, and (a) has never been pregnant. 
When a patient has been married a short time and gives a history 
of gonococcus infection with purulent vaginal discharge and smart- 
ing on urination, the probability is that if she has menorrhagia she 
is suffering with gonorrheal endometritis and perhaps with pyosal- 
pinx also. If gonococcus infection is not present menorrhagia in 
such a patient probably means uterine congestion due to excessive 



138 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

sexual intercourse. It may mean, however, a tear of the hymen 
from violent coitus, or a bleeding urethral caruncle. 

If there are any symptoms of pregnancy, such as a preexisting 
amenorrhea with sharp pain in one groin and tenesmus, irregular 
metrorrhagia might indicate extra-uterine pregnancy. In this 
case look for decidual membrane in the blood passed (see Chapter 
XIX., page 344), or it might mean an early abortion. The differen- 
tial diagnosis of these two conditions will be found in Chapter XXII., 
page 441. 

In the absence of the signs and symptoms referred to, metror- 
rhagia points to a uterine polyp. 

Menorrhagia becoming gradually metrorrhagia in a woman over 
thirty-five years of age suggests a submucous fibroid, and metror- 
rhagia occurring after forty, always should arouse suspicion of 
malignant disease; sterile married women and virgins being more 
prone to cancer of the body of the uterus than to cancer of the 
cervix, and parous married women to the latter. 

(b) The patient has been pregnant. If a pregnane}^ is not very 
distant in the past, metrorrhagia is probably due to subinvolution ; 
if metrorrhagia also is present, there may be retained products of 
conception, or inversion. Metrorrhagia coming on six weeks or 
so after labor may mean chorio-epithelioma. If pregnancy was in 
the distant past, endometritis in various forms, uterine displace- 
ments, fibroids, or cancer of the cervix must be thought of. Metror- 
rhagia beginning after the menopause has become well established 
almost invariably means cancer. 

(c) The patient is pregnant. Uterine hemorrhage beginning 
after one, two, or three months of amenorrhea, with the occurrence 
of some of the symptoms of pregnancy, points toward threatened 
abortion, and if regular rhythmic pains, like labor pains, are present 
also, to inevitable abortion. (See Chapter XXII., page 439.) 

Irregular hemorrhage, perhaps with the passage of decidual 
membrane, accompanied by pain in one groin and bearing down, 
with any symptoms of pregnancy may mean extra-uterine preg- 
nancy. (See Chapter XIX., page 351.) 

In the later months of pregnancy hemorrhage may be due to 
placenta previa or, rarely, to carcinoma of the cervix. 

The following table summarizes the facts as regards uterine 
hemorrhage in married women: — 



PRIMARY AMENORRHEA 



139 



MENORRHAGIA AND METRORRHAGIA IN MARRIED WOMEN. 
Menorrhagia. Metrorrhagia. 



f Uterine congestion. 

_, ... j Inflammation of tubes 

Multiparce. < , 

1 and ovaries. 

^Submucous fibroid. 



Following 
Pregnancy. 



f Sub-involution. 
\ Endometritis. 
[_ Submucous fibroid. 



During ( Rarely, menstruation 

Pregnancy. \ during pregnancy. 



Uterine polyp. 
Sub-mucous fibroid. 
Extra-uterine pregnancy 
Ruptured hymen. 
Cancer or sarcoma of the 

body of the uterus. 
Rarely, cancer of the cervix. 

Retained products of concep- 
tion. 

Cancer of the cervix. 

Inversion. 

Senile endometritis. 

Chorio-epithelioma, 

Rarely, cancer of the body of 
the uterus. 

f Threatened abortion. 
| Inevitable abortion. 
-^ Placenta prsevia. 

Extra-uterine pregnancy. 
^Rarely, cancer of the cervix. 



AMENORRHEA 



Amenorrhea, or absence of the menstrual flow (from d, privative, 
fiijv } month, and fiietv t to flow), may be classified as follows: — (1) 
Primary amenorrhea, or emansio mensium, in which menstruation 
has failed to appear at the usual age; and (2) secondary amen- 
orrhea, or suppressio mensium, in which menstruation has ceased 
after it has been established. 

i. Primary Amenorrhea. — Primary amenorrhea is due to (a) 
failure of growth of the uterine organs, perhaps coincident with 
lack of general bodily growth, perhaps not, or to (6) atresia of the 
hymen or of the vagina. The last condition, called cryptomenorrhea, 
is, strictly speaking, not amenorrhea at all, but a retention of men- 
strual fluid. As we are considering the symptom of absence of 
menstruation, it is convenient to include cryptomenorrhea in this 
place. 

(a) Failure of Growth. — A girl having a stunted physique may 
have tardy growth of the uterine organs also, and menstruation 



140 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

may appear later than normal. This, however, is not so often the 
case as it is to find a good physique and abnormal uterus and 
ovaries. The uterus which exhibits faults of development, such 
as uterus didelphys, uterus bicornis, and uterus bipartitus (see 
Chapter XIII. , page 199), does not ordinarily have amenorrhea as 
a symptom, although rudimentary uterus, when associated with 
atresia of the vagina, generally does. Arrests of growth, on the 
other hand, — infantile uterus and congenital atrophy of the uterus, 
— are commonly attended by amenorrhea. Infantile uterus is a 
relatively common condition. The uterus is narrow in proportion 
to its length, has a long cervix and a short body, and is situated 
well back and high in the pelvis at the end of a long vagina. The 
cervix is conical and anteflexed, and the os a " pin-hole os." The 
patient's figure, breasts, hair, and voice are generally of the fem- 
inine type. Congenital atrophy of the uterus is a rare condition. 
Here all the dimensions of the uterus are reduced while the normal 
proportions are retained. The condition has been found in dwarfs 
and cretins, and in early tuberculosis and chlorosis. It is supposed 
that in these cases the uterus attained a proper growth to the 
virgin type, and that atrophy followed. 

Both of these conditions are generally associated with anomalies 
of the ovaries. (See Chapter XVII. , p. 285.) Congenital absence 
of both ovaries is extremely rare. It is of course accompanied by 
absolute amenorrhea. Absence of one ovary does not affect men- 
struation. Faulty growth of the ovaries accompanies both infantile 
uterus and rudimentary uterus. The ovaries are small and amen- 
orrhea may exist. 

(b) Atresia of the Hymen, or of the Vagina. — Crypt omenorrhea 
may be caused by imperforate hymen (see Chapter XXL, page 396), or 
by the different varieties of atresia of the vagina (see Chapter XX., 
pages 357, 359). In these cases the ovaries are functionally active. 
Menstrual molimina are present and may be attended by severe 
cramp pains, and there may be vicarious menstruation from the 
nose or other mucous-mcmbrane-lined cavities. The menstrual 
fluid collects behind the obstruction, which may be situated any- 
where from the hymen to the internal os, though it is usually in the 
vagina, and by distending first the vagina, then the uterus, and 
finally the tubes, causes the conditions known as hematocolpos, 
hematometra, and hematosalpinx, respectively. 



SECONDARY AMENORRHEA 141 

The patient, who has passed the usual time for puberty, pre- 
sents a normal figure and has normal feminine breasts, hair, and 
voice. She complains of absence of menstruation and suffers with 
menstrual molimina— generally severe cramps in the lower ab- 
domen. 

2. Secondary Amenorrhea. — The following causes besides the 
menopause may be enumerated as accounting for the cessation of 
menstruation after it has been established: — (a) pregnancy and 
lactation, (b) atrophy of the ovaries, (c) constitutional diseases. 
(d) exhaustion and shock, and (e) retention of menses from 
acquired atresia of the genital canal. Cessation of menstruation 
may be temporary or permanent; if the latter, it constitutes the 
menopause. 

(a) Pregnancy and Lactation. — Pregnancy must be considered 
the chief cause of amenorrhea and the physician will do well to 
bear this constantly in mind, even in the cases where the probability 
of its being present seems to be small. It is to be remembered that 
menstruation may occasionally occur during pregnancy (see Chap- 
ter XXII., page 419). The menses are usually absent during 
lactation, though not always. Prolonged lactation may induce 
lactation atrophy of the ovaries with consequent amenorrhea. 

(b) Atrophy of the Ovaries. — Xot much is known about the con- 
ditions which cause atrophy of the ovaries. When atrophy has 
taken place the oophoron of the ovary, the egg-bearing zone, is 
smaller and harder than normal, and becomes transformed into a 
layer of dense fibrous tissue. 

Ovarian atrophy has been reported in women who have nursed 
their children a very long time, and also in the following diseases: — 
the exanthemata, myxedema, marked anemia, and diabetes. 
We are justified in supposing that cessation of function of the 
ovaries is the direct cause of amenorrhea in the 

(c) Constitutional Diseases. — Whether demonstrable degenera- 
tive tissue changes occur ordinarily when amenorrhea is present we 
do not know. There is no doubt that the ovaries show a decrease 
in size under such conditions. 

Suddenly acquired obesity is often attended by amenorrhea, so 
also are the early stages of pulmonary phthisis. In the former 
case it is apparently due to anemia and over-nutrition, and in the 
latter to anemia and malnutrition. Other instances of the latter 



142 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

cause are: tuberculosis of the kidney, diabetes, chronic nephritis, 
malaria, chronic mercury, lead, or alcohol poisoning, leukemia, and 
the morphine habit. 

If amenorrhea is not directly dependent on the blood state it is 
related to the condition of the nervous system. 

(d) Mental overwork in schoolgirls is sometimes responsible for 
the absence of the menstrual flow. Sudden grief, worry, or fear, 
or grave hysteria, melancholia, or some of the other psychoses, are 
often attended by amenorrhea. 

(e) Amenorrhea from retained menstruation due to atresia of the 
genital canal is comparatively rare. Necrosis of the vagina or 
cervix following prolonged and difficult labors, the wearing of 
neglected pessaries, or injury of the vagina from caustics, occasion- 
ally cause cicatricial stenosis to the extent that the secretions of 
the uterus are dammed up. In this event the absence of menstrua- 
tion will be attended by crampy pains and menstrual molimina. 

If a girl does not menstruate after she has passed her sixteenth 
year, the physician should inquire into the state of her general 
health, making whatever physical examination is necessary to 
arrive at a diagnosis of systemic disorder. The blood should be 
examined both as regards the number of red corpuscles and the 
percentage of hemoglobin. Failing to find any constitutional cause 
for the amenorrhea, a local examination should be made, and except 
in the rare cases of phlegmatic girls of good sense, with the aid of 
an anesthetic. 

Should the patient experience menstrual molimina without a 
flow, local examination should be made without a previous inquiry 
into the constitutional state. 

Neglect to investigate has resulted in serious harm in the cases of 
retained menstruation from imperforate hymen or atresia, through 
dilatation of the uterus and tubes with rupture of the latter into 
the abdominal cavity. 

In women who have been exposed to sexual intercourse, preg- 
nancy should alwaj^s be in the physician's mind as a probable cause 
of amenorrhea, and after the fortieth year the possibility of the 
beginning of the menopause should be considered. 

In every case of amenorrhea the general physical condition of 
the patient should first engage the physician's attention, — the 
nervous system and the blood state being thoroughly investigated. 



LEUCORRHEA 143 

LEUCORRHEA 

Leucorrhea, or "whites" (from /.tu-/.6? } white, and poia f flow), 
is the generic name commonly given to any discharge from the 
vulva, other than blood. 

Under normal conditions the inner surface of the vulva is simply 
moist during the intermenstrual time, except just before and just 
after menstruation, when the discharge may be enough to necessitate 
wearing a napkin. The normal moisture is made up of elements 
from four different sources, in varying amounts, namely: secretion 
from the uterine cavity proper, secretion from the cervical canal, 
epithelium from the vagina, and secretions from the vulva. The 
secretion from the uterine cavity is a clear, transparent fluid, small 
in amount, and having an alkaline reaction; that from the cervical 
canal is tenacious, transparent, and thick like the white of an egg. 
The epithelium cast off from the vagina is mixed with the uterine 
secretions to form a milky fluid which is generally small in amount. 

The sweat and sebaceous glands of the vulva make a secretion 
of considerable amount, forming smegma, which is found in the 
folds about the nymphse and under the prepuce. Besides this 
there is the glairy mucus secreted by the glands of Bartholin and 
Skene. 

Character of the Discharge ix Leucorrhea 

We will now consider the discharges under abnormal conditions, 
taking up first the different characters of the discharges and then 
the probable meaning of the various discharges occurring in girls 
and women of different social conditions. 

White Discharge. — It is white, creamy or curdy, or viscid and 
clear. It stiffens the linen but does not stain it. It may mean 
pelvic congestion, endometritis, or laceration of the cervix, with or 
without uterine malposition. 

Yellow Discharge. — It is light yellow (muco-purulent), markedly 
yellow (purulent), or greenish yellow (gonococcus infection). It 
may mean purulent endometritis, a pelvic abscess discharging 
through the vagina, pyometra associated with cancer of the cervix, 
and, most frequent of all, gonococcus infection of vagina, cervix, 
urethra, or the vulval glands. 



144 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

Watery Discharge. — This is a clear, colorless fluid that does not 
stiffen the linen. It may have color enough to stain the linen. 
It may mean uterine congestion, endometritis, intermittent hydro- 
salpinx, submucous fibroids, or cancer of the uterus, especially 
cancer of the body. Under watery discharge must be included 
leakage of urine from a urinary fistula or incontinence. Here the 
odor of urine is apparent. 

Fetid Discharge. — Foul-smelling discharge may be purulent or 
watery in character and results from necrosis of tissues. It may 
be caused by a neglected, retained pessary, by a sloughing sub- 
mucous fibroid or polyp, by decomposed products of conception, 
and, most frequent of all, by cancer of the uterus, especially cancer 
of the cervix; the discharge in the last case having a characteristic 
odor. 

Bloody Discharge. — A discharge tinged with blood, occurring dur- 
ing the intermenstrual period, stains and stiffens the linen. It 
may be due to endometritis, laceration of the cervix, submucous 
fibroid, polyp, vaginitis, or cancer. A scanty brownish discharge 
lasting for several weeks may indicate a disintegrating uterine decidua 
in the case of ruptured tubal pregnancy (see Chapter XIX., page 353), 
or it may mean the slow breaking up of a blood clot within the 
uterine cavity. 

Occurrence of Leucorrhea 

Leucorrhea in Children. — The immediate cause of leucorrhea in 
children is vulvitis. A white discharge occurs sometimes in poorly 
nourished children, and intestinal worms, dirt, and struma have 
been assigned as causes. Just how these are factors, and why some 
children affected by them have leucorrhea and others do not, has 
not been explained. One author has assigned the staphylococcus 
as a cause and others have found a large variety of bacteria in these 
cases. Masturbation is undoubtedly a cause of vulvitis and there- 
fore of leucorrhea with a white discharge, never of leucorrhea with 
a purulent discharge. The practice is by no means infrequent 
among neurotic children. (See Chapter XXVIII., page 574.) Pu- 
rulent vulvitis is due to gonococcus infection in a majority of cases. 
Recent bacteriological investigations of epidemics of this disease 
in institutions, public baths, and elsewhere prove that thegonococcus 



LEUCORRHEA U5 

is present in nearly all of the cases and that the disease is most 
frequent in children under five years of age. There occurs rarely in 
little girls a vulvo-vaginitis with purulent discharge, perhaps due 
to the staphylococcus. Vaginitis is generally associated with 
vulvitis, and salpingitis develops in a certain proportion of the 
cases. The disease leaves disabling traces not only in closure of 
the tubes but also in the form of adhesions of the nymphse to the 
prepuce and to each other. (See Chapter XXL, page 394.) 

Leucorrhea in Virgins. — Transitory leucorrhea in a virgin may be 
due to a pelvic congestion. The discharge under these conditions is 
generally either white and curdy, or clear and viscid, or a mixture 
of the two. Sometimes the leucorrhea if of the viscid type is from 
the secretion of the glands of Bartholin caused by sexual feelings. 
In only exceptional instances can a male physician ascertain the 
facts in this respect, so that if such a state of affairs is suspected 
the patient should be referred to a woman physician. Persistent 
leucorrhea in a virgin is due to pelvic congestion or endometritis 
in the young, or, in the old, may be due to cancer of the body of 
the uterus or to a submucous fibroid. Menorrhagia is generally 
an attending symptom. A local examination should be made 
because in this way only can an intelligent opinion be formed of 
the condition of the uterine organs. After the examination has 
been made the state of the general health should receive careful 
attention in the way of correcting anemia, whether or not local 
treatment is employed in conjunction with it. 

Leucorrhea in Married Women. — In women who are accustomed 
to sexual intercourse a white discharge ma}^ mean simple pelvic 
congestion. This is not an unusual condition in the recently mar- 
ried, the congestion of the pelvic organs being excessive because 
of intemperance in coitus. So also, a leucorrhea may result from 
habitual incomplete coitus, part of the discharge coming from the 
uterine cavity and part from Bartholin's glands. "Whites" are a 
symptom of laceration of the cervix, erosions, endometritis, and 
uterine misplacements. A yellow discharge is found in the vari- 
ous sorts of vaginitis (see Chapter XX., page 361). Vaginitis 
following infection during or after confinement is very common, 
and also gonorrheal vaginitis. The gonorrheal sort is apt to date 
from marriage or intercourse and to be accompanied by frequent 
and smarting micturition. A vulvo-vaginal abscess or a bubo may 

10 



146 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

have complicated the disease. Parous women are more apt to 
have cancer of the cervix than nulliparae. This disease is attended 
by a yellow or bloody vaginal discharge. Retained products of 
conception cause a bloody discharge, as a rule, and sloughing 
fibroids or polypi a foul, purulent discharge, while a submucous 
fibroid causes a thin, watery leucorrhea. A persisting brownish 
discharge may mean extra-uterine pregnancy. 

Leucorrhea in Old Women. — Women who have passed the meno- 
pause should have no vaginal discharge if their uterine organs have 
atrophied in a normal manner. If there is a white discharge it 
may be due to senile endometritis, caused by old-standing uterine 
lesions. A yellow or bloody discharge means either senile vaginitis 
or cancer, and so often the latter that no time should be lost in 
investigating the condition of the uterine organs as soon as the 
symptom is reported. 

DYSPAREUNIA 

Dyspareunia, from the Greek duv-dpeuvo?, ill-mated, is the 
name given to pain or difficulty in sexual intercourse. 

Difficulty in accomplishing the sexual act may be due to (1) 
psychoneurological, or to (2) anatomical causes. Of (1) the 
psychoneurological causes, we may enumerate repulsion or aversion 
on the part of the wife. Cases are on record where women have 
refused to let their husbands touch them throughout a long series 
of years of married life because of repulsion, or the husband's 
awkward manner of approach. Another of the psychoneurological 
causes is vaginismus (see Chapter XX., page 378), a spasmodic 
reflex contraction of the levator ani and other muscles about the 
vulva excited by the slightest touch. This affection may be 
associated with actual smalmess of the vagina or an irritable hymen, 
or it may be due entirely to an irritable condition of the nervous 
system. 

(2) Anatomical causes of both difficult and painful intercourse 
are (a) those situated in the vulva or lower vagina — a rigid hymen, 
a small vagina, either from faulty growth or from cicatricial stenosis, 
chronic vaginitis, urethral caruncle, vulvitis, a vulvo- vaginal 
abscess, chancres or chancroids of the vulva, and kraurosis vulvae; 
and (b) deeper-seated conditions, of which the chief are, — metritis, 



STERILITY 147 

lacerations of the cervix with tender cicatrices, prolapsed and 
tender ovaries, and masses of pelvic inflammatory exudate. It is 
unnecessary to consider here the acute inflammations of vulva, 
vagina, uterus, ovaries and tubes, or pelvic peritoneum because, 
of necessity, intercourse could not take place in the presence of 
such conditions. 

Disproportion between the size of the penis and the caliber of 
the vagina, or a deficiency in the lubricating fluids secreted by the 
prostate in the male and Bartholin's glands in the female, may be 
causes of dyspareunia. 

In getting a history of pain during intercourse the physician must 
inquire whether the pain is at the beginning, or after the penis has 
entered the vagina. If at the beginning, the cause is probably to 
be sought in vaginismus or in class (a) of the anatomical causes; if 
after the penetration of the male organ the cause is in class (b). 
Inquiry should be made whether the pain has been present with 
coitus since the beginning of married life, or has been noted follow- 
ing the occurrence of any of the symptoms of pelvic disease. 

Physical examination will reveal all of the anatomical causes and 
also vaginismus. 

STERILITY 

Sterility, from the Latin word sterilis, barren, meaning, when 
applied to a woman, that she has not borne a living child, — not that 
she is unable to, — is classified as absolute (primary) sterility where 
no child has been borne and no miscarriage, or no abortion has 
taken place, as relative (secondary) sterility where one or more preg- 
nancies have occurred, followed by a period of unfruit fulness, or fac- 
ultative sterility, infertility caused by the prevention of conception. 

Sterility may be due either to the husband or to the wife, possibly 
to both, therefore no physician should submit a woman to local 
treatment for sterility without first assuring himself that the 
husband's organs of procreation are functionating normally. This 
is done by questioning, by an examination of the penis and testicles, 
and by a microscopical examination of semen spent into a glass 
vial, which is then corked and kept warm at the body temperature, 
by placing it in warm water. Questioning, not in the presence of 
the wife, will determine whether the man thinks that coitus is 



148 



THE CHIEF SYMPTOMS OF PELVIC DISEASE 



performed normally, or whether he has noticed any abnormality of 
his generative organs, or has had gonorrhea. Examination of the 
penis and testicles by the physician may detect some anomaly that 
the patient had not suspected: — it may show a gleety urethra] 
discharge. Microscopical examination of the semen on a warm 
slide will show whether it contains living spermatozoa or not. 
Care must be exercised not to heat the bottle containing the semen 
too much or to let it get cold, or the spermatozoa may be killed. 

Sterility in the Male 

The frequency with which the fault lies with the husband in 
cases of sterility is obviously a matter difficult to determine. San- 
ger, and Lier and Ascher (quoted by Kelly, "Medical Gynecology") 
have studied this matter in a number of cases. Of 242 husbands of 
sterile marriages examined by these authors, 104, or 43 per cent, 
showed absence of living spermatozoa, or deficiency of semen and 
impotency, the proportions being, respectively, 79 cases, and 25 
cases. Further, 55 of the men had infected their wives with 
gonorrhea, producing, as the authors assume, indirect sterility. 

A fair inference from these statistics, by three competent observ- 
ers, is that in something over half of the sterile marriages the fault 
lies with the husband, hence the importance of investigating the 
man as well as the woman. 



Sterility in Women 

Age as a Factor. — As pointed out by Matthews Duncan and shown 
in the following table, the age at marriage is the chief factor in the 
expectation of sterility. 



Age at Marriage. 


15-19 


20-24 


25-29 


30-34 


35-39 


40-44 


45-49 


Percentage of wives bearing a 
child within two years .... 


43.7 


90.5 


75.8 


62.9 


40.9 


15.4 


4.3 






From this it will be seen that fecundity is greatest in women 
who have been married between the ages of twenty and twenty-four, 
and decreases progressively until the menopause. 



STERILITY 



149 



Duncan has shown also by his statistics that of the wives married 
between the ages of twenty and twenty-four who were all fertile, 
only six and two-tenths per cent began to bear after three years 
of marriage. In other words, when the expectation of fertility is 
greatest the question of probable sterility is soonest decided. 

The age of the wife has a bearing on sterility, for, according to 
this same author's statistics, the following percentages were 
observed : — 



Age of Wives at 

Marriage. 



15-19 


20-24 


25-29 


30-34 


35-39 


40-44 


45-49 


50 and 
over. 


700 


1,835 


1,120 


402 


205 


110 


46 


29 


51 





311 


151 


109 


100 


44 


29 


7.3 





27.7 


37.5 


53.2 


90.9 


95.6 


100 



Total. 



Number of wives 

observed 

Sterile wives 
Percentage sterile 



4,447 
725 
16.3 



Other Factors. — The factors essential for procreation, as far as the 
woman is concerned, are, the presence of a living ovum, a healthy 
endometrium upon which the ovum may develop, permeability of 
the genital tract so that the spermatozoon may reach the ovum, 
and secretions of the genital tract that are not inimical to the life 
of the spermatozoon, or that do not bar its upward progress to the 
ovum. 

Entrance of the penis into the vagina is not necessary to produce 
conception, for cases are on record where pregnancy has occurred, 
and women have come to labor even, with an unruptured hymen 
which presented only a minute opening; therefore deposition of 
semen on the vulva is all that is necessary in some cases. Also, 
sexual feeling is not a necessity, for women have conceived 
after intercourse while unconscious from intoxication and other 
causes, and artificial insemination has produced conception. Still, 
conception is more likely to occur if the penis enters the vagina and 
if sexual feelings with an orgasm are present, the spermatozoa, in 
all probability, finding a more ready entrance to the uterine cavity 
during the orgasm. 

Leaving out of account the question of age, already considered, 
the following may be enumerated as causes of sterility in women: — ■ 
(1) Bars to conception in the form of anomalies and diseases of the 
uterine organs. (2) Conditions of the uterine organs causing 
interruption of pregnancy and death of the fertilized ovum or fetus 



150 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

(abortion and extra-uterine pregnancy) , and (3) Constitutional 
diseases and general causes acting either in preventing conception, 
or in terminating it after it has begun. 

1. Anomalies and Diseases of the Uterine Organs. — The following 
is a list of the pelvic diseases commonly found associated with 
sterility, beginning with the vulva and ending with the ovaries : — 

Imperforate or rigid hymen (preventing penetration). 

Tumors of the vulva (preventing penetration). 

Urethral caruncle (dyspareunia). 

Absence or atresia of the vagina (preventing penetration). 

Vaginismus (preventing penetration). 

Vaginitis (destruction of spermatozoa by discharges, especially 
gonorrhea). 

Rupture of the pelvic floor (allowing semen to run out). 

Inversion of the vagina with uterine prolapse (preventing in- 
semination). 

Infantile uterus (lack of normal endometrium). 

Anteflexion of the uterus (mechanical obstruction, together with 
endometrial discharges). 

Endometritis and polypi (abnormal endometrium and discharge). 

Erosions of the cervix (spermatozoa barred, or killed by dis- 
charge). 

Lacerations of the cervix (spermatozoa barred, or killed by 
discharge). 

Cancer of the cervix and body (spermatozoa barred, or killed 
by discharge). 

Fibroids of the uterus (unknown direct cause). 

Hyperin volution of the uterus (abnormal endometrium). 

Nodular and obliterating salpingitis (very frequent cause, 
especially of one-child sterility. » Canal of tube obstructed by 
nodules or closed by adhesive inflammation). 

Under-development or atrophy of the ovaries (oophoron of 
ovary affected, so that healthy ova are not produced, or are not 
thrown off). 

Ovarian tumors (all of functionating oophoron destroyed, or 
ova can not reach tubal ostium). 

Adhesions about the ovaries (same as ovarian tumors). 

2. Conditions of the Uterine Organs that Cause Interruption of 
Pregnancy. — The chief local causes of abortion are: — 



VESICAL SYMPTOMS 151 

Pelvic congestion from excessive coitus. 

Endometritis (abnormal endometrium). 

Retroclisplacements of the uterus (preventing the progressive 
enlargement of the uterus). 

Lacerations of the cervix (through endometritis and lack of 
protection of the ovum or fetus). 

Syphilis of the placenta or decidua. 

Introduction of foreign bodies, such as catheters, into the uterus. 

Follicular salpingitis (furnishing diverticula for the development 
of extra-uterine gestation). 

3. Constitutional Diseases and General Causes. — The chief con- 
stitutional affections that either cause failure to conceive, or in- 
terrupt pregnancy are : — 

The acute diseases, especially the infectious diseases, such as 
acute rheumatism, scarlatina, and typhoid fever. 

Alcoholism and morphinism. 

Syphilis (frequent cause. From syphilis of placenta and 
decidua, or transmitted from father through semen). 

Excessive obesity, occurring rapidfy. 

Anemia, associated with chronic heart disease, kidney disease, 
diabetes, or tuberculosis. 

The psychoses (mental diseases or sudden nervous shocks). 

Inbreeding (marriage of cousins). 

Masturbation (chronic pelvic congestion from conjugal onan- 
ism, simple masturbation, or douches). 

VESICAL SYMPTOMS 

The chief symptoms of disease or derangement of function of the 
urinary organs are : — 

(1) Difficult, retarded, or painful urination, dysuria. 

(2) Too frequent urination, frequent micturition. 

(3) Incontinence of urine, enuresis. 

(4) Retention of urine, ischuria. 

(5) Suppression of urine, anuria. 

i. Dysuria, from the Greek words, dus, ill, and oupov, urine, 
signifies an inability to start the stream and to empty the bladder, 
and also pain attending the act of micturition. When the urine 
is passed drop by drop with spasmodic pain the condition is known 



152 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

as strangury (from arpdy^ i a drop and ohpov } urine). It is found 
in cystitis, especially in those forms of cystitis that are due to 
poisoning by cantharides or turpentine. 

Painful or difficult urination is a very common symptom com- 
plained of by women who suffer with gynecological affections. 
Some authors estimate the number of such women who have vesical 
symptoms as high as one-half of all the cases applying to the 
physician for relief. A greater or less degree of dysuria almost 
invariably accompanies pelvic inflammation and also gonococcus 
infection, but more of this later. 

The physician will do well to rule out first the general constitu- 
tional causes of dysuria. Pain and burning during urination may 
be due to a too acid or too concentrated urine. This is the case in 
patients who habitually ingest a small quantity of fluids and also 
in lithemic women. Sometimes this symptom is indicative of 
acute nephritis, because then the urine is concentrated. The 
ingestion or absorption, through the lungs or skin, of turpentine 
may cause dysuria, and in the same manner cantharides, mustard, 
and pepper, when taken internally or applied to the skin, may be 
attended by this bladder symptom. 

The local causes of dysuria, beginning at the meatus urinarius, 
are, urethral caruncle (see Chapter XXIII. , page 453). Here the 
pain may be so severe that the nervous system is upset and the 
patient becomes melancholic. The pain is described as " scalding," 
"stabbing," " shooting," or " cutting," and is felt while the urine 
is passing over the caruncle and for some little time afterward. 
The pain is apt to be aggravated during the menstrual period, and 
the dread of the pain is often so great that urination is deferred as 
long as possible, so that retention may result. In many of these 
cases there is a constant pain in the vulva as well as the pain which 
attends micturition, the constant pain being aggravated by walking. 

Dyspareunia generally accompanies dysuria in these cases, and 
there may be bleeding on coitus. 

Urethritis is due in a great majority of cases to gonorrhea and is 
a common cause of dysuria. Anything that increases the con- 
gestion of the pelvic organs, such as menstruation or pregnancy, 
exaggerates the inflammation of the urethra, and therefore increases 
the severity of the symptom of difficult or painful micturition. 
(See Chapter XXIII., page 450.) 



VESICAL SYMPTOMS 153 

Doionivard dislocation of the urethra is a not infrequent cause of 
difficulty in passing urine, and so is stricture of the urethra, one of 
the results of urethritis. Suburethral abscess generally causes 
difficulty in urination. It is a subacute disease and is attended by 
pain, fever, dyspareunia, and the intermittent discharges of pus. 

The causes of dysuria that are situated in the bladder are: — 

(a) Calculi and foreign bodies, which are usually attended by 
cystitis; (6) cystitis in its various forms (see Chapter XXIV., page 
462) ; and the (c) new growths of the bladder, the most frequent of 
which are papilloma and cancer. 

2. Too Frequent Urination. — The time-worn term " irritable 
bladder" has given way to a more rational and more exact descrip- 
tion of both the symptoms and the pathological conditions present. 
To establish the fact of too frequent urination, the physician must 
inquire as to the patient's habit as regards emptying the bladder. 
Many women are accustomed to void urine only at long intervals 
of time, perhaps once or twice a day. Perhaps they ingest very 
small quantities of fluids. Under the influence of excitement, of 
taking more fluids, or of cold, the amount of urine may be larger, 
and the desire to pass it consequently more pressing and more 
frequent. On the other hand, a small amount of fluid taken by 
the mouth and abundant perspiration will diminish the amount 
of urine secreted, and therefore the necessity for passing it. 

Inquiry into too frequent urination should deal with the custom 
of the individual under ordinary conditions of health. How many 
times by day, and how many times by night. Too frequent urina- 
tion must be differentiated from incontinence, and this will be 
taken up in the section on incontinence. 

Most conditions which make micturition painful also cause it 
to be too frequent. This is the case with the inflammations of the 
pelvic organs. Here we are considering only the affections which 
are chiefly distinguished by abnormal frequency. 

During pregnancy the urethra and the neck of the bladder partake 
of the congestion of all the pelvic organs at this time. Why this 
congestion of the neck of the bladder is attended by too frequent 
micturition in some pregnant women and not in others we do not 
know. 

The statement may be made that, as a general rule, micturition 
is more frequent during pregnancy, especially during early preg- 



154 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

nancy, than at other times. Women who suffer with uterine 
disease may have too frequent micturition onfy at the time of 
menstruation because of the additional congestion of the neck of 
the bladder at that .period. 

The ingestion of large quantities of fluids, especially of those 
which have a diuretic effect, like tea, coffee, and beer, is followed 
by frequent micturition, so also are diabetes mellitus, diabetes 
insipidus, and hysteria, because of the secretion of an abundant 
supply of urine in these diseases. 

Urethritis and stricture of the urethra are causes of frequency, — 
even congenital smallness of the meatus may cause frequency. 
Contracted bladder, by not permitting any considerable quantity of 
urine to accumulate, causes frequency, and so do tumors of the 
bladder situated in the neighborhood of the vesical trigone. 

Cystitis is attended by increased frequency of micturition, in 
fact it is a cardinal symptom, but there are no data in hand to 
show that increased frequency is due to ureteral or kidney disease 
where the bladder is not at the same time affected, although put 
from a suppurating kidney, in the same manner as concentrated 
urine, — perhaps containing crystals, — may stimulate the bladder 
neck and cause frequency of urination, also the passage of a renal 
calculus along the ureter may cause a reflex desire to urinate. The 
bladder is so frequently involved in cases of pyelitis and ureteral 
calculus, however, that frequency of urination may be considered 
a symptom of these diseases. 

3. Incontinence of Urine {Enuresis). — 1. Local Causes. — Inability 
to control the escape of urine from the bladder, or the passing of 
it unconsciously, may be due first of all to an overdistended bladder. 
In this event the urine escapes a little at a time and the patient 
may not realize that the bladder is overfilled; her complaint being- 
only that her clothes are wet or that she can not control the urine, 
permanent incontinence exists in vesico-vaginal fistula, also in 
vesico-uterine and uretero- vaginal, or uretero-uterine fistula. (See 
Chapter XXIV., page 474.) 

Incontinence is a feature in epispadias, downward dislocation 
of the urethra, and in some cases of prolapse of the uterus, and in 
cystocele. In the latter cases the urine may escape only when the 
intra-abdominal pressure is increased in laughing, coughing, sneez- 
ing, or straining. 






VESICAL SYMPTOMS 155 

2. General Causes. — Nocturnal enuresis is a form of incontinence 
found in children. Here large quantities of urine are voided, quite 
unconsciously, at night only, the affection being supposed to be 
caused by an over reflex excitability of the nervous mechanism of 
the bladder. Rarely a local abnormality, such as an adherent 
prepuce, may act as a cause. 

Incontinence may be due to a disorder of the brain itself (a), or 
(6) to some affection of that portion of the spinal cord which puts 
the brain into communication with the vesical centers in the sacral 
segments of the cord. 

(a) The conditions which inhibit conscious cerebral activity are: 
coma, from whatever cause, as alcohol, epilepsy, or cerebral hem- 
orrhage; some insanities; sunstroke; shock, and the poisons of 
some of the infectious diseases, as diphtheria and typhoid fever. 

(b) The lesions which interfere with the conduction between the 
brain and the vesical centres in the lower cord are: myelitis, 
injuries and tumors of the cord, spinal meningitis, and locomotor 
ataxia. 

If the reflexes are entirely abolished total paralysis of the bladder 
with retention and dribbling of urine ensues; if the paralysis is 
partial, there will be partial retention, with occasional voiding of 
urine and its involuntary escape after voluntary urination is 
finished. The last happening is a frequent occurrence in locomotor 
ataxia. 

4. Retention of Urine (Ischuria). — The urine may be retained in 
the bladder and the patient unable to void it in the same diseases 
of the brain and spinal cord as in the case of incontinence just 
noted. It is a pretty constant symptom of multiple sclerosis. 
Retention often alternates with incontinence in cases of coma 
and the typhoid state. Retention is common in hysteria, and in 
order that overdistention of the bladder may be avoided, the 
physician should palpate and percuss the lower abdomen of the 
hysterical woman to detect a full bladder. Retention is not un- 
common during late pregnancy, and, whatever the cause, may result 
in a lack of expelling power and atony of the bladder. Retention 
is to be expected in incarceration of the retroflexed pregnant uterus, 
and may occur, rather infrequently, in fibroids and ovarian tumors. 
Retention has occurred because of blocking of the urethra by a 
suburethral abscess, or by cancer of the urethra. Temporary re- 



156 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

tention has been caused by the occluding of the urethra by a cal- 
culus or a pedunculated tumor of the bladder, and lodgment of a 
stone in the ureter may produce retention by causing spasm of the 
sphincter vesicae. 

5. Suppression of the Urine (Anuria). — If urine is not secreted, or 
if secreted does not reach the bladder, the condition is known as 
suppression of urine, or anuria. The catheter must be passed and 
the bladder found empty before anuria may be said to be present. 

Anuria, a rare condition, may occur in hysteria, in uremia, during 
the terminal stage of chronic nephritis, in acute nephritis, or in 
poisoning by turpentine, lead, phosphorus, or cantharides. Sup- 
pression of urine has been noted in yellow fever, typhoid fever, and 
the late stages of acute yellow atrophy of the liver, and in sunstroke. 

In hysterical anuria the diagnosis is established by passing the 
catheter and then repeating the procedure after a definite interval 
of time, — say two hours, when the patient does not expect it, — 
thus obviating conscious or unconscious malingering. If both 
ureters are obstructed by disease within, or by pressure from with- 
out (see Chapter XXV., page 489), so that no urine reaches the 
bladder, the condition is known as obstructive anuria. This is a 
rare condition, the diagnosis being made by cystoscopy and ure- 
teral catheterization. 

RECTAL SYMPTOMS 

In taking the history, certain facts pointing toward rectal disease 
are to be noted; among them are the occurrence of slight morning 
diarrhea, continuing over a long period of time and alternating with 
attacks of constipation, a sense of weight in the pelvis, dull pain, 
in the region of the sacrum, and pain or swelling of the left lower 
limb. 

Pain. — As to pain, ask when it was first noticed, the exact situa- 
tion, how long the attack usually lasts, what effect has defecation 
upon it, and how severe it is. The most probable cause of pain 
occurring over a long period of time is fissure. When of recent 
occurrence, pain may be due to fissure, complete fistula, blind 
internal fistula, or prolapsed internal piles. If the pain is in the 
anus the chances are that the lesion is there, whereas if it is in the 
region of the sacrum the lesion is probably in the rectum proper. 



FECAL SYMPTOMS 157 

If the pain lasts after defecation for several hours, the probable 
diagnosis is fissure or blind internal fistula, or complete fistula with 
a large internal opening. Pain ceases after defecation in the case 
of stricture, but in the case of piles the pain persists as long as the 
piles are outside the sphincter. 

Pain following defecation indicates fissure, blind internal fistula, 
prolapsed internal piles, or a protruded polypus or tumor. Pain 
accompanying constipation and relieved only by emptying the 
rectum, is probably due to impaction of feces, ulceration, or stricture. 
Pain or itching, coming only after the patient has gone to bed, may 
mean external piles or eczema about the anus. 

Hemorrhage. — Hemorrhage from the rectum is either (a) associ- 
ated with defecation, or (b) it is independent of defecation. 

(a) Bleeding internal piles and fissure cause loss of blood with 
the stools. When the feces passed are only smeared with a little 
blood, the diagnosis may be ulcer of the rectum. Profuse hemor- 
rhage sometimes accompanies defecation in the case of internal piles, 
a slight hemorrhage being more usual in cases of prolapse, polyp, or 
villous tumor. 

(b) Hemorrhage independent of defecation occurs in some cases 
of internal piles, cancer, and, in the case of prolapsed growths, in 
prolapse of the mucous membrane, in internal piles, and in polyp. 
Continuous hemorrhage seldom lasts more than twenty-four hours 
and, as a rule, hemorrhage in rectal disease is intermittent. Blood 
may come from the skin around the anus in the case of eczema, 
fissures, external piles, or tuberculosis in that region. 

Rectal Discharge. — Besides blood, there may be discharged from 
the rectum, mucus, muco-pus, and serous fluid. An increase in 
the amount of the rectal mucus is found in proctitis, in internal 
piles, in prolapse, and in stricture with invagination of the rectum. 

In the case of chronic hypertrophic proctitis the amount of 
mucus passed per anum, often involuntarily, is so great that the 
patient is forced to wear a napkin. Pus is due to an abscess which 
has ruptured into the bowel, or to a fistula-in-ano. Muco-pus is 
generally found in ulceration, whether malignant or simple. 

Serous fluid is passed in cases of villous tumor, often in large 
quantities and involuntarily. Besides making inquiry on these 
points the patient's linen should be inspected. 

Fecal Accumulation. — The rectum is almost always found filled 



158 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

with feces in cases of fissure, internal piles, eczema of the anus, and 
hypertrophy of the external sphincter from whatever cause. In 
the case of stricture of the rectum the accumulation of feces will be 
found above the stricture, not below. The symptoms of this 
condition may be nothing more than a sense of fulness in the rectum, 
or there may be no symptoms. Digital examination makes the 
diagnosis. The physician should have the probabilities in mind 
before making the examination. 

Difficulty in Defecation. — With this condition there is present a 
more or less constant desire to empty the bowel, and defecation is 
not attended by relief. It is not the same as constipation. If the 
dread of going to stool is due to pain caused by the act, the probable 
diagnosis is fissure, or ulcer, or a partly torn off polyp, causing 
spasm of the sphincter. If there is a tightness of the sphincter, 
the muscle will be found hypertrophied and non-dilatable. If there 
is much pain with straining before and during defecation and 
disappearing entirely after defecation, leaving a sense of only 
partial relief, a stricture is probably present. 

Character of the Feces. — Diarrhea is not a true diarrhea unless it 
consists of a frequent discharge of fecal matter, whether solid, semi- 
solid, or fluid. True diarrhea is not frequently met with in rectal 
disease. If the feces are passed in short pieces of small caliber, with 
a little mucus and blood, or pus and blood, a stricture is probably 
present. If there is much blood and the feces are not in small 
pieces, cancer is to be suspected. In prolapse or invagination of 
the rectum, the feces are apt to be scybalous. 

Protrusion from the Anus. — This occurs in internal piles, polyp, 
and pedunculated tumors, including villous tumors and cancer. If 
the protrusion is associated with defecation, the tumor returning to 
the rectum spontaneously soon after, — the probable diagnosis is 
internal piles, a polyp with short pedicle, a moderate degree of 
prolapse, or a villous tumor. When the protrusion remains down for 
several hours, the probable diagnosis is internal piles which have 
become pedunculated, a polyp with long pedicle, a marked degree of 
prolapse, or a villous tumor, and also, if protrusion occurs on stand- 
ing or straining, it is probably due to an extreme degree of any of 
these. The affections referred to in the preceding section will be 
found described at length in Chapter XXVI. , pages 498, and 
523-525. 



COCCYGODYXIA 159 



COCCYGODYNIA 

The term coccygodynia (from ■/.<>/.-/.•/= ^ coccyx, and Sd6vrj } pain) 
is the name given by Sir James Y. Simpson to pain in the region of 
the coccyx, an affection occurring almost entirely in women and 
generally due to injury of the coccyx during labor. Some time 
previous to May, 1844, Dr. J. C. Nott, of Mobile, Alabama, removed 
the last two coccygeal bones in a young unmarried woman for 
''neuralgia of the coccyx/' due to caries of the coccyx, following 
injury from a fall. This is the first recorded instance of coccy- 
godynia, which is very commonly associated with gynecological 
affections. 

Cocc3'godynia may occur in men when due to injury, but it is 
extremely rare. As in Xott's case, the disease in woman may be 
associated with caries of the bone; this is, however, rare, and the 
pathological appearances of the specimens removed by operation 
show most often disease of the joint between the first and second 
coccygeal bones. The three lower bones are generally ankylosed 
in adults so that forcing them backward, — as in labor, — or forward, 
as in a fall on the buttocks when the thighs are flexed, places the 
strain on the only movable joint, that between the first and second 
pieces. Besides injury to the joints the coccyx may be fractured. 
The etiology of the pain is obscure and some authors attribute it to 
rheumatism of the muscles in the neighborhood of the coccyx, 
others to sprains of the ligaments, and still others to some affection 
of Lushka's coccygeal gland, which has a rich nerve supply. 

The symptoms consist of continuous pain in the region of the 
coccyx aggra vated by sitting down and by rising from a sitting 
posture. A hard seat causes especially severe pain and pain is 
exaggerated by defecation and by coitus. Mild cases are fairly 
common, but severe ones are infrequent. In the bad cases there 
may be constant pain along the entire length of the spinal column ; 
the patient may get up from a sitting posture by placing the palm 
of one hand upon the seat of the chair and the other on any con- 
venient support, and pushing the body up by the arms as much as 
possible, so as to avoid contracting the muscles of the pelvic floor 
and the glutei. The bad cases are usually the victims of 
neurasthenia. 



160 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

In making the diagnosis, tenderness of the coccyx to light pres- 
sure, both from the skin surface and by a finger in the rectum, is the 
chief feature. If there is dislocation the lower bones of the coccyx, 
grasped between the finger in the rectum and the thumb in the 
crease of the nates, may be thrown out of line with the upper bone, 
or bones. A fracture may be felt as a ridge on the surface of the 
coccyx. 

Tenderness over the coccyx by both vaginal and rectal digital 
examination may be found in proctitis (see Chapter XXVI., page 
506), therefore in establishing the diagnosis of coccygodynia this 
disease must be ruled out. 



PRURITUS VULVJE 

Pruritus vulva?, or itching of the vulva, is a symptom which 
may be the source of a great deal of misery to its victim, and may 
lead to serious derangement of the health from loss of sleep and 
constant nervous irritation. In the severe grades it is often accom- 
panied by evidences of impairment of the nervous system, such as 
frequency of micturition, indigestion, irritability of temper, and 
instability of disposition. It is a symptom and is undoubtedly 
due to a certain sort of irritation of the terminal filaments of the 
nerves in the skin of the vulva, but the pathology is, as yet, unknown. 
The causes of pruritus may be divided into: (1) irritating dis- 
charges from the vagina or bladder, (2) diseases of the vulva, and 
(3) neuroses. 

i. Irritating discharges from the vagina are, (a) leucorrhea from 
chronic endometritis. Leopold holds that this is a very common 
cause of pruritus; also leucorrhea from vaginitis, as in gonorrhea, 
is a not uncommon cause of itching. 

(b) The urine of diabetes is a frequent cause of pruritus. The 
patient complains of great thirst, drinks large quantities of water, 
and is hungry most of the time. Examination of the vulva shows 
slight redness about the orifice of the urethra, redness and perhaps 
induration of the labia, and excoriations from scratching. The 
urine has a sweetish smell and on examination is found to contain 
sugar. Pruritus is often the first symptom which leads to the 
diagnosis of diabetes. 



PRURITUS VULVAE 161 

(c) The urine of cystitis, or nephritis, may cause pruritus, but 
this is not a common happening and usually yields readily to treat- 
ment for the urinary difficulty. 

2. Diseases of the vulva causing pruritus are, first, (a) congestion 
of the vulva and varix of the vulva, both commonly found in preg- 
nane} 7 , in uterine or ovarian tumors, or in any obstruction to the 
venous return of the blood in the pelvis, — such as intra-abdominal 
pressure on the vena cava. Even the congestion of the menstrual 
period may be accompanied by itching. 

(b) Vulvitis and kraurosis vulvae are attended by more or less 
pruritus, the latter, generally by intense itching. 

(c) Pediculus pubis is a cause of itching. On careful inspection 
of the hairs of the vulva the parasites or their nits are readily seen 
and are destroyed by shaving the parts and anointing with a ten- 
per-cent solution of carbolic acid and olive oil. 

(d) Thrush of the vulva is a cause of pruritus, and in little girls 
(e) simple uncleanliness seems to operate as a cause. (/) Eczema 
of the vulva is nearly always attended by severe itching. 

3. Neuroses. — Under this head we may include, (a) masturba- 
tion, although it is doubtful whether the itching is not the cause of 
the masturbation, rather than the reverse. There can be no doubt, 
however, but that constant handling and irritation of the clitoris 
and vulva make for hypersensitiveness and therefore exaggeration 
of a predisposition to pruritus. 

(b) Oxyuris vermicularis, or pin-worms, found in the rectum in 
children, cause itching not only about the anus but of the vulva 
also. In pruritus vulvae in a child this cause, as well as uncleanli- 
ness, should be always sought for. 

(c) Pruritus is common at the menopause without discoverable 
lesions of the vulva, and is observed sometimes also in (d) women 
having a rheumatic diathesis. 



11 



PART II 

SPECIAL DIAGNOSIS 



CHAPTER XI 

THE DIAGNOSIS OF ENDOMETRITIS, INCLUDING 

GONORRHEA AND EROSIONS OF THE 

CERVIX UTERI 

Anatomy and physiology of the endometrium, p. 166. 

Pathology, p. 169. 

Anatomico-pathological classification, p. 170. 

Endometritis from a clinical point of view, p. 173: Acute non-gonorrheal 
endometritis, p. 173; Etiology, p. 173; Symptoms, p. 174; Signs, p. 176. 
Chronic non-gonorrheal endometritis, p. 176; Varieties, p. 176, (1) Of 
puerperal origin, or post-abortum, p. 176, (2) Those varieties which are not 
preceded by a known acute stage, p. 177; Etiology, p. 177; Symptoms, 
p. 177; Signs, p. 178. Gonorrheal endometritis and gonococcus infection, 
p. 179. Acute gonorrheal endometritis, acute gonorrheal endocervicitis, p. 
180; Symptoms, p. 181, Diagnosis, p. 181, Differential diagnosis, p. 181; 
Chronic gonorrheal endometritis, p. 182: Latent gonorrhea in women, 
p. 182; Differential diagnosis of chronic gonorrheal endometritis, p. 183. 
Senile endometritis, p. 183. Endocervicitis, p. 184. Erosions of the cervix 
uteri, p. 184: Characteristics, p. 184; Diagnosis, p. 185; Differential 
diagnosis, p. 186. 

Although endometritis is a part of the inflammatory process 
called Pelvic Inflammation, it may exist without involvement of 
the periuterine structures. As pelvic inflammation is most often 
caused by infection introduced through the vagina and uterus, so 
endometritis is generally a beginning stage of pelvic inflammation. 
The term endometritis will be used to define inflammation of the 
endometrium. 

Endocervicitis is the name given to the inflammatory process 
when it is limited to the cervix. The differentiation of endocer- 
vicitis from endometritis of the body has a practical importance 
in the acute infections, especially in gonococcus infection, and 
also in the chronic form of inflammation where the disease is apt 
to be situated chiefly in the cervical canal. An inflammatory 
process situated in the endometrium may extend to the muscular 
structure of the uterus, and then the process may be defined more 
exactly as a metritis. 

In practice the diagnosis of metritis aside from endometritis 

165 



166 THE DIAGNOSIS OF ENDOMETRITIS 

is an academic affair and of no practical significance even when 
it is possible to diagnose one without the other; therefore, little 
will be said of metritis, with the understanding that in the severe 
grades of endometritis there is present also metritis. 



ANATOMY AND PHYSIOLOGY OF THE ENDOMETRIUM 

A word as to the anatomy and physiology of the endometrium 
before taking up the consideration of the different manifestations 
of inflammation. The following description applies to the un- 
impregnated uterus of the healthy adult woman between menstrual 
periods. It will be noted that the mucosa of the cervical canal 
is anatomically and physiologically different from the mucosa of 

___ the uterine cavity proper, therefore 

y<^ """"^V we are justified in considering the 

/'.V. ^y\ word endometrium as applying to 

/ ^-- ~.iz^< v foe latter only. 

\i;- ""■— —^ .-_.,. • -y The interior of the uterus is 

^m. , / x-yv divided into two cavities: the cavity 

\^~^x r=== ^! zr ^^ / of the body, and the cavity of the 

In ~!7 neck, which are separated from each 

\ ■ other by the constricting ring of 

V;; {mmi^ >7' muscular tissue about the internal 

N^jU~==tr^ t os - ^ ne shape of these cavities has 

J^\ ;***«»; ^7 been referred to elsewhere, the cav- 

\ ^ / / ity °^ ^ ne b°dy being represented by 

1j| ij y an inverted isosceles triangle with 

Fig. 64. — Reconstruction of the two angles of the base in the 

Uterus, Showing Shape of Uterine uterine cornua and the third angle 

Cavity and Cervical Canal. (Wil- ^ ^ ' mim ^\ 0S . The anterior 

hams.) 

and posterior walls of the uterus 
meet at the sides at an acute angle so that there are no lateral 
walls proper, therefore the uterine cavity is flattened from before 
backward. The cervical cavity is fusiform in shape, largest in 
the middle and contracted at the internal and external ora. 

Under resting conditions the cavity of the body is closed against 
infection from below at the internal os and from infection from 
above by the muscular constrictions at the isthmuses of the Fallopian 
tubes. The cavity of the cervix in like manner is protected from 



ANATOMY AND PHYSIOLOGY 167 

infection from above by the narrowing at the internal os, and from 
below in the nulliparous uterus more, and in the parous uterus 
less, by the constriction at the external os. 

The wall of the uterus is made up of three layers, the thin, serous, 
peritoneal layer, the thick muscular layer — composing most of 
the structure of the uterus — and the medium thick mucous layer. 
The mucous layer, the endometrium, consists of the utricular 
glands, connective tissue, blood-vessels, nerves, and lymphatics. It 
is covered by a single layer of ciliated columnar epithelium — which 
also lines the glands — and is continued through the Fallopian tubes. 









&i 



■~*X:.::.;-:iSZ^J£. 



: <"''M 



Fig. 65. — Normal Endometrium. (Williams.) 

The endometrium is essentially a glandular structure. The 
glands are tubular and branching, several opening often by one 
mouth. They extend into the muscular layer and all open into the 4 
uterine cavity. In the body of the uterus the endometrium is 
closely united to the muscularis, whereas in the neck it is freer. 
In the cervix uteri the lining epithelium shades into pavement 
epithelium at the external os. In this cavity the mucous mem- 
brane is thrown into oblique ridges which diverge from an anterior 
and posterior longitudinal raphe, presenting an appearance which 
has received the name of arbor vitae. 



168 THE DIAGNOSIS OF ENDOMETRITIS 

The normal secretion of the uterine glands is a clear, watery 
fluid, having an alkaline reaction, that of the glands of the neck is 
clear and viscid; it is also alkaline. Throughout the cervical 
mucosa are found a variable number of little cysts, presumably 
glands, which have become occluded and distended with retained 
secretion. They are called the ovula Nabothi, or Nabothian 
follicles. 

The endometrium shows normally many differences in structure 
from infancy to old age and during the intermenstrual and menstrual 
cycles. 

Before puberty it is relatively thin and undeveloped, nearly all 
of it having the character of the cervical mucosa. 

Our views as regards the normal histology of the endometrium 
have of recent years undergone a considerable change, due to the 

important observations of Hitschmann and 
Adler (Monatssclnift fur Geburts. und 
Gynaekol.j 1908, XXVII. , 1), confirmed 
by several subsequent investigators. 

Hitschmann and Adler, after a painstak- 
ing study of the uterine mucosa from fifty- 
eight women at various periods of the 
t- nn Tr • i ^ x menstrual cycle, found that the endome- 

Fig. 66. — Virginal Exter- J ' 

nal Os. (Williams.) trium from the cessation of one menstrual 

flow to that of the next, presents a con- 
stantly changing histological picture. This cycle of changes they 
divide into four phases; postmenstrual, interval, premenstrual, 
and menstrual. At the height of the menstrual flow the mucous 
membrane diminishes in thickness and the glands pour out their 
secretion, becoming narrow and straight. The surface epithelium 
is frequently lost, but this is not an invariable rule. After the 
period there takes place a very rapid cell growth in both the 
epithelium and connective tissue. The glands become larger and 
wider, although still quite narrow and straight. The epithelium 
is low and in a condition of rest. By about the fifteenth da)^ the 
cell growth of the epithelium has progressed to such an extent that 
the glands become somewhat tortuous, and often assume a spiral 
or corkscrew-like appearance. Finally, six or seven days before 
the beginning of menstruation, the glands rapidly enlarge and 
become tortuous, the cells bulge into the lumen, the epithelium 





PATHOLOGY 169 

becomes higher and broader, and the lumen is filled with a 

mucous secretion. These gland changes are much more marked 

in the deeper portion of the mucosa than in the superficial, so that 

there is produced a well-marked differentiation into a superficial 

compact and a deep spongy layer. In this 

respect there is a marked similarity to 

the appearance of the young decidua, the 

resemblance being increased by the fact 

that the interglanclular stromal cells in 

many cases assume an appearance very 

similar to or approaching that of decidual 

cells 

Fig. 66a. — Parous Exter- 
During pregnancy the mucosa of the cor- nal 0s . (Williams.) 

pus uteri is enormously congested. Its 

fimction is the formation of the decidua — the connective-tissue 

cells of the endometrium going to make the decidual cells of 

pregnancy. 

Following the menopause there is an atrophy of the endometrium 

coincident with the shrinking of the uterus so that in the old 

woman the uterine glands are found almost entirely obliterated, 

and there is apt to be partial or complete closure of the uterine 

canal at the internal os. 

PATHOLOGY 

It is probable that all forms of endometritis are due to bacterial' 
invasion of the endometrium. The endometrium under normal 
conditions is sterile, and bacteria in small numbers introduced 
from without are promptly destroyed. Although chemical irrita- 
tion and trauma may cause congestion and favor bacterial growth, 
the idea that these influences and " constitutional taints" do any- 
thing more than provide a fertile soil for the microorganisms has 
gone the way of many older theories. 

The following bacteria have been found in the endometrium in 
cases of endometritis — seldom in pure cultures, generally in mixed 
infections: — 

Staphylococcus pyogenes albus, citreus, and aureus. 

Streptococcus pyogenes. 

Gonococcus. 



170 THE DIAGNOSIS OF ENDOMETRITIS 

Colon bacillus. 

Tubercle bacillus. 

Diphtheria bacillus. 

Typhoid baccillus. 

Pneumococcus. 

Bacillus aerogenes capsulatus. 

Spirochaeta pallida of syphilis. 

In many forms of endometritis the bacterium reaches the endo- 
metrium from without by way of the vagina ; in a smaller number 
of varieties it comes from the Fallopian tubes or abdominal cavity 
through the lumen of the tubes; and in still other varieties it comes 
through the lymphatics and veins of the uterine wall from near-by 
sources of infection in peritoneum, rectum, or bladder; and rarely 
it reaches the endometrium from distant sources through the blood 
current. 

The classification of endometritis has long been a stumbling 
block to the gynecologist. A recent writer on the subject gives a 
pathological classification containing eleven different forms, accord- 
ing to the macroscopic or microscopic appearances of the different 
varieties, and a clinical classification of ten different sorts of chronic 
endometritis. 

A bacteriological classification will ultimately be the one chosen 
as a guide to diagnosis. At present, not enough facts are known 
to justify its use. As it is impossible to diagnose the different 
varieties according to the pathology, except by examination of 
scrapings from the endometrium, and, according to the present state 
of our knowledge of the pathology of the endometrium, the differ- 
entiation of the varieties has no bearing on the treatment, we shall 
consider the subject from the clinical point of view. Suffice to 
mention the forms of endometritis which have been recognized as 
a result of the microscopic examination of scrapings and of uteri 
removed by operation. 

ANATOMICO-PATHOLOGICAL CLASSIFICATION 

Hypertrophic endometritis, in which the endometrium is thickened 
and soft. If the glands are increased in size only, it is called 
hypertrophic glandular endometritis, if they are increased in number 
it is called hyperplastic glandular endometritis. 



ANATOMICO-PATHOLOGICAL CLASSIFICATION 



171 



F. Hitschmann and L. Adler (Zeit. f. Gebs. u. Gun., 1907, LX., 
63) state that endometritis glandularis hypertrophica and endo- 
metritis glandularis hyperplastica have nothing whatsoever to do 
with inflammation. The first is not even a pathological condition of 
the uterine mucosa but corresponds to the premenstrual .state of the 
normal lining of the uterus; the latter consists partly of the normal 
premenstrual condition, and partly of variations in the number of 
glands within physiological limits; in addition it includes cases in 
which there is a glandular hypertrophy of the uterine mucous 
membrane, but this also is a change which is entirely independent of 
inflammation. 

There is, according to these investigators, but one variety of 
inflammation of the uterine mucosa, endometritis interstitialis, or, 
as it is usually called, en- 
dometritis. The diagnosis 
is made by demonstrating 
the cells of infiltration, so- 
called plasma cells. 

If the inflammatory proc- 
ess affects chiefly the inter- 
glandular connective tissue 
the process is known as in- 
terstitial endometritis. This 
form has an acute and a 
chronic stage, the acute 
being characterized by dif- 
fuse or circumscribed infil- 
tration of the stroma by small round cells with congestion of the 
blood-vessels and a serous exudate in the spaces of the connective 
tissue 1 (exudative interstitial endometritis). The chronic stage is 
characterized by newly formed connective tissue resulting in com- 
pression of the utricular glands, and, in the later stages in atrophy 
of the endometrium, the so-called atrophic endometritis. 

Retention cysts may be formed in the interglandular spaces of the 
connective tissue and cystic interstitial endometritis results, or the 
glands may be obstructed by the pressure of the connective tissue 
at their mouths, cystic glandtdar endometritis. Fungous endome- 
tritis is the term applied when the mucosa is tin-own into folds; 
villous endometritis, when it is covered with shaggy villosities; and 




Fig. 67. — Horizontal Section of the Up- 
per Part of the Body of the Uterus. 



172 



THE DIAGNOSIS OF ENDOMETRITIS 



polypoid endometritis, when one or more mucous polyps are 
present. When a layer of necrotic tissue, composed of degenerated 
epithelium, blood, leucocytes, microorganisms, and fibrin is found 
on the surface of the endometrium — as in certain infections follow- 
ing labor and abortion— the condition is known as pseudodiph- 
theritic endometritis, and when true ulcers form in the endome- 




F'ig. 68. — Transverse Longitudinal Section of the Uterus. 

trium — as in carcinoma and tuberculosis— the process is called 
ulcerative endometritis. 

Decidual endometritis is the name given to inflammation of the 
endometrium during pregnancy. It is diagnosed definitely by 
microscopic examination of the deciclua after expulsion of the fetus. 
Evidences of inflammatory action are present. The symptoms 
may be hydrorrhea uteri gravidi, or pains in the uterine region 
during pregnancy. 

A rare condition is exfoliative endometritis, so-called membranous 
dysmenorrhea. It consists of the discharge from the uterus of a 



ACUTE NON-GONORRHEAL ENDOMETRITIS 173 

more or less incomplete cast of the cavity of the corpus uteri, in 
the shape of a sac, triangular in form, gray in color, and of a rough 
surface. Floated in water and laid open, its interior is smooth. 
When examined under a- magnifying glass it is seen to be studded 
with minute openings which represent the mouths of the utricular 
glands. When the sac is reasonably complete the openings of the 
Fallopian tubes may be distinguished at the upper angles of the 
sac. The membrane is from one to three millimeters thick and 
under the microscope shows much the appearances of exudative 
interstitial endometritis, although the pathological appearances vary 
in different cases. 

Tuberculous endometritis, relatively rare, is a sequel often of 
primary tuberculosis of the tubes. Rarely it is primary in the 
cervix. Tuberculous infection may reach the endometrium also 
from without by coitus, or by instrumental or digital interference. 
Occurring in the late stages of general tuberculous infection of the 
genito-urinary system, it has no clinical importance, because the 
other manifestations of the disease are of overshadowing seriousness. 
It is characterized by the presence of giant cells, tubercles, and 
tubercle bacilli found microscopically in scrapings made from the 
endometrium. The tubercle bacilli may be detected in the uterine 
discharges. Many cover-slip preparations should be studied before 
affirming the absence of the bacillus. 

Not much is known of the forms of endometritis occurring after 
the acute infectious diseases — typhoid fever, diphtheria, scarlet 
fever, measles, and smallpox — nor of the endometritis which 
attends syphilis. 

Gonorrheal endometritis will be considered separately under the 
clinical classification. 

ENDOMETRITIS FROM A CLINICAL POINT OF VIEW 

The subject is best divided into acute and chronic endometritis, 
with special consideration of gonorrheal endometritis, senile endome- 
tritis, and endocervicitis. 

Acute Non-goxorrheal Endometritis 

Etiology.— This is an inflammation due to invasion of the 
endometrium by septic microorganisms, more especially the 
staphylococcus and the streptococcus. It is a grave form of en- 



174 THE DIAGNOSIS OF ENDOMETRITIS 

dometritis as contrasted with a majority of the chronic forms of en- 
dometritis, which are of a mild type and have no recognizable 
acute stage. 

Its chief causes are: (1) infection following labor and abortion; 
(2) the use of uncleanly fingers or instruments in making office 
treatments; (3) operations which are not aseptic, and (4) sloughing 
intra-uterine tumors. 

(1) Infection following labor and abortion is the most frequent 
cause of acute endometritis. It can not be entirely avoided even 
with the most scrupulous care. Retained membranes may de- 
compose and cause it. Too often the physician is to blame. 

Bacteria brought to the vagina on carelessly washed hands, lack 
of thoroughness in the preparations for the immediate repair of 
the injuries of the pelvic floor and perineum following labor, the 
unnecessary use of forceps, or too frequent vaginal examinations, 
to say nothing of too much douching — thereby washing away 
the normal secretions of the vagina, which, according to Doder- 
lein destroy pathogenic bacteria — all play an important part. 
The great danger of so-called septic endometritis, which attends 
criminal abortion, is too well known to require extended comment. 

(2) The general practitioner of medicine, realizing the necessity 
of washing his hands after an examination, is careless about washing 
them before making a vaginal examination or instrumental treat- 
ment. The practice of making intra-uterine office treatments is 
dangerous even with strict asepsis, besides being useless as a 
therapeutic measure. Passing the sound into the uterine cavity 
should be clone only under strict aseptic precautions and with the. 
utmost gentleness to avoid trauma. 

(3) Minor operations may cause as great harm as major ones and 
too commonly do so because the preparations for the lesser pro- 
cedures are not as carefully made. 

(4) Sloughing of a uterine polyp, of a pedunculated submucous 
fibroid, or of an inverted uterus sometimes results in septic endo- 
metritis unless prompt operative measures are instituted. 

Symptoms. — The symptoms of acute endometritis with septic 
absorption, acute septic endometritis, manifest themselves within 
twenty-foil* to forty-eight hours after infection, although they may 
be delayed for several days. Their severity depends upon the form 
of infection. A septic intoxication which is due to the absorption 



ACUTE NON-GONORRHEAL ENDOMETRITIS- 175 

into the system of ptomaines. — the product of decomposition set 
up by bacteria, — is called sapremia; that which is due to the 
absorption of the bacteria themselves with their toxins is known as 
septicemia proper. As yet we have no means of determining which 
form of infection is present in any given case. We know that the 
form caused by the streptococcus is the more grave, that the 
streptococcus may be diffused very rapidly throughout the system, 
and that in death resulting from this form there may be found few 
pathological changes in the pelvic organs. The staphylococcus, on 
the other hand, is more apt to produce marked local reaction and 
pus formation. The severity of the symptoms will vary according 
to the continued presence of the source of infection and the rapidity 
of its absorption. Although the endometrium is the point of en- 
trance of the infective material into the system and endometritis 
is the first manifestation of the poisoning, the disease is a general 
one almost from the first. In the later stages of the disease the 
involvement of tissues neighboring to the endometrium — the uterine 
muscle, pelvic cellular tissue, the Fallopian tubes, and peritoneum — 
produces complications which overshadow the endometritis. The 
symptoms are ushered in by a severe chill, followed by elevation 
of temperature (103°-104° F. or higher), and a rapid pulse (110- 
120 or higher). If the disease follows labor or abortion the lochial 
discharge is diminished in amount at first and then increased, be- 
comes dark in color, then purulent, and generally, though not in the 
streptococcic form, has an offensive odor. If the disease does not 
follow labor or abortion a bloody, purulent, usually offensive uterine 
discharge is a constant symptom after the initial chill. Intermittent 
uterine pains— becoming continuous and severe if the inflammatory 
process reaches the peritoneum — nausea, constipation, and frequent 
and painful micturition are early symptoms. 

Irregularly recurring chills, high temperature, rapid and feeble 
pulse, a sense of well-being and apathy, the characteristic un- 
described odor of sepsis, diarrhea, and failing strength, are symptoms 
of the advanced stages of the disease. 

Acute endometritis without sapremia or septicemia, is attended by 
comparatively slight constitutional disturbances and the symptoms 
are limited to elevation of temperature— generally preceded by a 
chill — pain of moderate severity in the lower abdomen, frequeni 
and painful micturition, nausea, and disturbance of menstruation 



176 THE DIAGNOSIS OF ENDOMETRITIS 

either suppression or menorrhagia. The symptoms abate in a few 
days. 

Signs. — In all forms we find on physical examination, — the uterus 
enlarged and soft, tender to light pressure in all parts; the vagina 
hot and dry; the uterine discharge wanting at first and later 
increased in amount. The os is patulous. Rigidity and tenderness 
of the abdominal muscles, called peritonismus, is to be expected 
if the peritoneum is involved in the inflammatory process, other- 
wise not. Acute endometritis without complications is uncommon. 

If the case is seen early an anesthetic should be given because of 
the great pain caused by manipulation. Thorough aseptic precau- 
tions are observed. A soimd is passed into the uterus and retained 
membranes, or sloughing tumors, polypi, or fungosities are detected 
by sound-touch. In cases of doubt the cervix should be dilated 
until it will admit the operator's finger, and the interior of the uterus 
explored by touch, all adventitious tissue being removed either 
with the finger, curette, or curette forceps, and preserved in a ten- 
per-cent formalin solution for microscopic examination. 

Chronic Non-gonorrheal Endometritis 

Varieties. — Chronic endometritis may be divided into: (1) those 
forms of acute endometritis that have terminated in a chronic form, 
and (2) the varieties which present no acute stage demonstrable 
by clinical methods. 

(1) The forms of acute endometritis which have become chronic are 
commonly of puerperal origin, or post-abortum. Some of the 
pathological varieties are, — pseudodiphtheritic, decidual, and 
ulcerative endometritis. A chronic endometritis resulting from 
an acute septic endometritis generally has as complications one or 
more of the following affections: — metritis, cellulitis, peritonitis, 
pelvic abscess, or salpingitis. When the inflammatory process is 
centered chiefly in one of the situations just enumerated, the in- 
flammation of the endometrium is less active and the physical signs 
indicate that in the endometrium the fire has, as it were, burned 
out, leaving only smouldering embers. Microscopic examination of 
the endometrium reveals one or more of the different stages of 
glandular and interstitial endometritis as described on pages 170 
and 171. 



CHRONIC XOX-GOXORRHEAL EXDOMETRITIS 177 

If septicemia is present the symptoms are those of chronic 
septicemia; fluctuating elevations in the temperature, rapid and 
feeble pulse, dry skin, diarrhea, the odor of sepsis, malnutrition, and 
anorexia. 

There being no septicemia the symptoms are leucorrhea, uterine 
hemorrhages, menstrual disturbances, clyspareunia, sterility, and 
abortion, and symptoms referable to the digestive and nervous 
systems. 

Leucorrhea is the only constant symptom. The discharge is 
profuse, — though varying in amount in individual cases. It is 
purulent in character and may be mixed with blood. It is, as a 
rule, odorless unless it has been retained on the vulva and has 
decomposed because of the patient's uncleanly habits. 

A history of an acute attack of septic infection and the character 
of the leucorrhea — especially if septic microorganisms can be 
found in it upon microscopic examination of cover-glass prepara- 
tions — serve to distinguish this form of endometritis from 

(2) The large number of varieties of chronic endometritis which are 
not preceded by a known acute stage. They may be enumerated 
as: — fimgous, villous, polypoid, exfoliative, and tuberculous. 

The endometritis of the infectious diseases — typhoid fever, 
diphtheria, scarlet fever, measles, small-pox, and syphilis — all 
are of a mild type. 

Etiology. — Predisposing causes of chronic endometritis are: — 
uterine displacements, uterine malformations (especially ante- 
flexion), subinvolution of the uterus, extensive lacerations of the 
cervix, tumors of the pelvis, sexual excesses, chronic constipation, 
the infectious diseases, and certain constitutional diseases, — anemia, 
chlorosis, rheumatism, and lithemia. 

The pathological processes present are glandular and interstitial 
endometritis as described on pages 170 and 171. 

Symptoms. — The chief symptom is leucorrhea. The patient does 
not remember when she first noticed a vaginal discharge, so gradual 
is its beginning. It is due to the secretion of the utricular glands 
plus that of the vulvovaginal glands. The amount depends on 
the condition of the endometrium, — more when it is hypertrophied 
and in the glandular variety of endometritis, and less in the atrophic 
variety. In the fungous and polypoid forms the leucorrhea is apt 
to be bloody, and, if there is decomposition of tissues, purulent. In 

12 



178 THE DIAGNOSIS OF ENDOMETRITIS 

most of the varieties of chronic endometritis the discharge is thin 
and serous in character. 

When the secretion from the cervical canal exceeds in amount 
that from the body of the uterus the discharge is thick and 
viscid in consistenc}^ It is without odor and is unirritating as 
a rule, although in patients of uncleanly habits it may have a 
foul odor. 

The amount of discharge varies from a staining of the linen to 
several well-soaked napkins a day; it is increased for a day or two 
just before and just after each menstrual period because of the 
normal congestion of the genital organs at these times. 

Hemorrhage at the menstrual period or excessive menstrual 
flow — styled menorrhagia — is to be expected in the hypertrophic 
form of endometritis; scanty flow in the atrophic forms. Painful 
menstruation — dysmenorrhea — is a pretty constant symptom, 
although it occurs in such great variety of manifestations and at 
such variable times with reference to the flow that it is impossible to 
dogmatize about it. Irregularity in the occurrence of menstruation 
also is to be expected, variations of a few days before or after the 
normal time being common. 

Sterility and abortion are more often observed in patients suffer- 
ing from chronic endometritis than in women with normal uterine 
organs. Symptoms of general ill health usually accompany chronic 
endometritis, although it is not always easy to determine whether 
the ill health is due to the endometritis or the endometritis to the 
ill health. 

Signs. — The physical examination reveals a uterus enlarged, but 
not necessarily to a marked degree, and more or less sensitiveness 
of the uterus to light pressure when it is squeezed between the ex- 
aminer's fingers during the combined vagino-abdominal or recto- 
abdominal touch. If the uterus is occupied by polypi it will be felt 
to be fatter than normal, and often a polypus, having been elon- 
gated and driven down b} 7 the uterine pressure, presents at the 
external os. 

On speculum examination a discharge is seen to be issuing from 
the external os. Its character is noted. A tough stringy mucus 
is the characteristic of the secretion of the glands of the cervix; 
a thin, watery discharge is from the glands lining the cavity of the 
corpus uteri. The alkalinity of the discharge should be tested 



ENDOMETRITIS AND GONOCOCCUS INFECTION 179 

with a piece of litmus paper. In endometritis the reaction is often 
neutral or even acid. The condition of the neck of the uterus is 
noted, — whether lacerated or eroded or not. 

On passing the uterine sound the cavity of the uterus is generally 
found to be enlarged. In anteflexion with endometritis the in- 
ternal os is tight, but the operator will find that by straightening 
the canal by traction on the cervix with a tenaculum it is always 
possible to pass a sound of small caliber. Previous to passing the 
sound an accurate idea should be obtained as to the probable 
direction of the uterine canal by means of the bimanual touch. 
Great gentleness is essential. 

If the sound is passed with the greatest care and blood flows after 
its withdrawal and the cavity is tender, endometritis may be 
diagnosed. Fungosities and polypi are to be detected in favorable 
cases by the tactile sense transmitted through the sound, i.e., when 
the canal is widely open and reasonably straight. Points of ten- 
derness in the endometrium and their definite situations are deter- 
mined by the sound. 

Gonorrheal Endometritis and Gonococcus Infection 

Gonorrheal endometritis merits special consideration because it 
is a very common disease and has serious sequelae. 

As to its frequency authors do not agree. It is undoubtedly 
more common in the public clinics and among prostitutes than in 
private practice. Zweifel estimated that ten per cent of his private 
gynecological cases suffered from gonorrhea. Different writers 
place gonorrhea as the cause of acute inflammation of the uterus 
and tubes in from one-half to two-thirds of the patients seen in the 
dispensary services of the large cities. This estimate includes 
some of the puerperal cases, which form a considerable number of 
the total acute infections, for the gonococcus, as well as the staphy- 
lococcus and the streptococcus, is the cause of puerperal infection. 

The gonococcus, a diplococcus discovered by Neisser in 1S7 ( .), 
finds a favorite habitat in the deeper portions of the mucous mem- 
branes which are covered with cylindrical epithelium. It also 
grows readily under pavement epithelium, but can not penetrate 
the squamous epithelium as easily as the columnar. 

Its favorite homes in the female generative apparatus when once 



180 THE DIAGNOSIS OF ENDOMETRITIS 

introduced are, in order of frequency: — (1) the urethra and 
Skene's and Bartholin's glands; (2) the mucosa of the cervical 
canal; (3) the upper portion of the vagina; (4) the endometrium 
of the corpus uteri ; (5) the mucosa of the Fallopian tubes. 

Although the squamous epithelium of the vagina of adults, 
bathed in its acid secretions and protected by its normal bacterial 
flora, resists the invasion of the gonococcus, the tender vaginal 
mucosa of children, although covered by squamous epithelium, is 
easily penetrated by it, whence the frequency of vulvo-vaginitis 
among children. 

The gonococcus is speedily destroyed by other bacteria and their 
toxins in the case of a secondary infection in the process of abscess 
formation, as attested by the rarity with which it is found in the 
contents of a chronic pyosalpinx; on the other hand it may remain 
alive in the mucosa of the cervical canal or in Skene's glands for a 
series of years. As a rule gonorrheal infections are uncompli- 
cated by mixed infections with other bacteria unless trauma 
accompanies the infection. 

The diplococcus is always introduced from without — in little 
children by the contaminated fingers of an adult infected with the 
diseases and by soiled linen or bath sponges — in adults, as a rule, 
by coitus. 

Gonorrheal endometritis invariably begins in the cervical canal. 
It may be limited to the cervix uteri if the internal os is well closed, 
— as in virgins and in anteflexion. In muciparous women it is 
prone to spread to the corpus uteri. Sometimes the gonococcus is 
carried from the cervix to the corpus uteri by the physician's sound 
or uterine applicator. The disease is acute or chronic. 

Acute Gonorrheal Endometritis 

The disease is limited to the cervix, acute gonorrheal endocer- 
vicitis. The mucosa of the cervical canal is reddened, swollen, and 
bathed in pus, which sometimes has a greenish tinge. The neck is 
swollen, soft, and tender to the touch. Examined histologically 
the mucosa shows loss of epithelium in places; the uterine glands 
show hypertrophy and hyperplasia, and the interglandular tissue 
is enormously infiltrated with round cells and polymorphonuclear 
leucocytes. The blood-vessels arc increased in number and size. 



ACUTE GONORRHEAL ENDOMETRITIS 181 

On staining for the gonococcus it is found lying in groups between 
the epithelial cells and also in the subepithelial tissue. The 
gonococci may also be found in the pus. They seldom penetrate 
the uterine muscle by way of the lymphatics as do the streptococci, 
and when gonorrheal inflammation reaches the peritoneum it does 
so by way of the mucosa of the corpus uteri and of the Fallopian 
tubes. 

Symptoms. — The symptoms of acute gonorrheal endocervicitis are 
generally marked by the symptoms of coincident inflammation in 
the urethra, vulvovaginal glands, and vagina. There is a history 
of infection. The symptoms are ushered in by a chill followed by 
an elevation of temperature and a rapid pulse. The patient com- 
plains of pelvic pain, painful micturition and defecation, nausea 
and vomiting, and, in the course of a few hours, there is a leucorrhea, 
— at first mucous in character, soon becoming purulent and some- 
times mixed with blood. The symptoms are not so severe as in 
acute septic endometritis, and last not over a week. They are more 
pronounced if the inflammation has extended to the body of the 
uterus, and still more so if to the Fallopian tubes. In these cases 
one looks for greater pelvic and abdominal pains. 

Diagnosis. — The diagnosis rests on (1) the history of a suspicious 
intercourse, which was followed by a purulent vaginal discharge, 
and by preceding frequent and painful micturition, i.e., an acute 
urethritis, strong presumptive evidence of gonorrhea; (2) the 
symptoms just enumerated; (3) the physical signs. The cervix is 
swollen and tender, and pus flows from the os. If the mucosa of 
the corpus uteri is also involved — acute gonorrheal endometritis — 
the entire uterus is enlarged and tender to bimanual touch; (4) 
the microscopic examination of the pus shows the presence of the 
gonococcus. 

Differential Diagnosis. — The acute form of gonorrheal endome- 
tritis may be mistaken for acute septic endometritis. In the 
gonorrheal form the local and constitutional symptoms are less 
severe, there is lacking a cause for sepsis in the form of post-puer- 
peral infection or intra-uterine treatment, and on the other hand 
there may be presenl a history of a suspicious intercourse. The 
urethra, Skene's glands, and the vulvo- vaginal glands are involved; 
there may be enlargement of the lymphatic glands of the groin- 
adenitis, bubo — finally the gonococci are found in the discharge. 



182 THE DIAGNOSIS OF ENDOMETRITIS 

Chronic Gonorrheal Endometritis 

Chronic gonorrheal endometritis may result from a well-marked 
acute gonorrheal endometritis. More commonly the history of 
an acute stage is wanting. The history of frequent and painful 
micturition, either following marriage or in a woman suspected of 
having loose habits, whether married or single, should lead the 
physician to consider the possibility of gonorrhea. 

The onset of the disease is generally insidious; the symptoms 
and physical signs are those of the varieties of chronic endometritis 
due to the saprophytic and pyogenic bacteria. 

The leucorrhea in gonorrheal endometritis is generally most 
abundant; it loses the purulent character of the acute stage and 
is mucous in character. The diagnosis depends on finding the 
gonococcus in the discharge from the cervix. Some authors claim 
that it is necessary to make cultures in order to identify surely the 
microorganism, but this view is not held by most. Many slides 
should be examined. Negative findings do not rule out gonorrhea, 
and this brings us to the consideration of latent gonorrhea. 

Latent Gonorrhea in Women. — Certain experiments by Wertheim 
of Vienna (Archiv. fur Gyn., 1892, XLL, No. 1), and clinical 
observations by a number of investigators, go to show that the 
gonococcus loses its virulence after a time — weeks or months — 
that when it is planted in new ground, i.e., when another indi- 
vidual is infected, the microorganism recovers its former vitality, 
and that when reintroduced into the original host all the symp- 
toms and signs of an acute attack of gonorrhea are manifested. 
For example, a man has acute gonorrhea which ends in a chronic 
gleet. He infects his wife and later is reinfected by her and has 
another acute attack of gonorrhea. In the course of time each 
becomes tolerant of the gonococci of the other. The husband has 
intercourse with a prostitute, suffers a fresh attack and reinfects 
his wife. This explains why the gonococcus, even after years of 
apparent cure, may regain its full virulence. Such authorities as 
Wasscrmann (Bed. Klin. Woch., 1897, No. 32, p. 685), Maslovski, 
DeChristmas, and Jullien agree that there is no immunity in gon- 
orrhea, one attack giving no exemption from the disease in the 
future. It argues for repeated examinations of a gleety urethral 
discharge in the male before advising marriage. 



SENILE ENDOMETRITIS 183 

The cervical canal and Skene's glands in the floor of the urethra 
are the chief lurking places for the gonococcus in the female genital 
apparatus. 

Differential Diagnosis of Chronic Gonorrheal Endometritis. — 
Chronic gonorrheal endometritis may be mistaken for the simple 
forms of endometritis. A gonorrheal origin of an endometritis 
may be suspected from the history of the case ; — an acute attack 
with purulent discharge and painful micturition following a sus- 
picious intercourse. Occasionally there is a history of the patient 
having had a bubo or gonorrheal inflammation of the joints. More 
commonly no such history is obtainable. It is seldom advisable 
to institute too minute inquiries in this direction in the case of 
married women because of the risk of causing trouble between 
husband and wife, — trouble which can not be cured by the physician. 

Tubal disease is found in conjunction with all forms of endome- 
tritis, but more commonly with the septic and gonorrheal forms. 

In most cases repeated bacteriological examinations of the dis- 
charge from the cervix are the only way of distinguishing to a 
certainty the cause of the inflammatory process. The results of the 
examinations are so often negative that we are left with only a 
probable diagnosis founded on the history alone. 

Senile Endometritis 

Senile endometritis is an atrophic form of endometritis occurring 
in women who have passed the menopause, occurring particularly 
in poorly nourished subjects. It is due to the infection of the 
atrophying mucosa, but what causes the infection is not known. 
Pathologically the endometrium is found thinned, the glandular 
elements are wanting, and many times the endometrium is entirely 
replaced by connective tissue. There may be stenosis of the 
uterine cavity from adhesion of the walls, and, from the same cause, 
the retained secretions may form a senile pyometra or hydrometra. 
The latter is very rare. The symptoms have an insidious ousel, a 
thin, purulent, often offensive and irritating vaginal discharge 
being the chief symptom. Pruritus vulvae is common, also vulvitis. 
Sometimes the discharge is tinged with blood. There may be 
symptoms of mild sepsis if the discharges are retained, and in this 
case pelvic pains are to be expected. 



184 THE DIAGNOSIS OF ENDOMETRITIS 

The physical signs show the uterus to be small (unless there is 
pyometra) , and the cervix uteri is atrophied. An attempt to pass 
the sound will reveal partial or complete atresia of the uterine canal. 
If the canal is patent the discharge is seen issuing from the os. The 
disease, coming as it does after the menopause and attended as it is 
by a foul discharge, may be mistaken for carcinoma of the cervical 
canal or body of the uterus. Dilatation and curetting, with an 
examination of the tissue removed, will settle a doubt. 

Endocervicitis 

Endocervicitis is a chronic inflammation of the mucosa of the 
cervical canal. It is called also cervical catarrh and cervical 
endometritis. The disease is confined to the cervix uteri, — there 
is no extension to the mucosa of the corpus uteri. This is a common 
affection. The gonorrheal form has been described under chronic 
gonorrheal endometritis. Lacerations of the cervix are a frequent 
cause. When the cervix is torn the lips become everted and are 
subjected to trauma from (1) pressure on the posterior wall of the 
vagina by scybalous masses in the rectum resting on the unyielding 
sacrum, or (2) from excessive coitus. Another common cause of 
endocervicitis are polypi originating either in the mucosa of the 
cervix or corpus. 

The cervical tissues in endometritis become hypertrophied, the 
mucosa is eroded, and cystic degeneration develops. Infection is 
difficult to dislodge as the bacteria occupy the glandular crypts. 

Erosions of the Cervix Uteri 

Characteristics. — Erosions of the cervix uteri are characterized 
by a dark red or purplish color of the tissues immediately around 
the external os uteri. Having the appearance of ulceration they 
were formerly believed to be true ulcers. 

In an erosion there is no inflammatory action accompanied by 
destruction of the epithelium as in ulceration. The surface 
squamous epithelium, which normally covers the cervix, is re- 
moved, — it is eroded, — and the underlying columnar epithelium is 
hypertrophied. 

(1) A simple erosion presents a uniformly smooth, velvety surface 



EROSIONS OF THE CERVIX UTERI 



185 



with sharply defined edges. On microscopic examination it is 
seen to consist of a single layer of columnar epithelium with little 
or no formation of new glands. 

(2) A papillary erosion has an irregular projection of its livid 
red surface and has been called "cock's-comb granulations." Here 
the microscope shows deep invaginations of the columnar epithe- 
lium to form glands, alternating with elevations made up of newly 
formed connective tissue and round cells. The glands secrete a 
viscid mucus. 

(3) A follicular erosion is one in which retention cysts — the so- 




Fig. 69. 



-Erosion of the Cervix with Lacerations. 
(H. Macnaughton- Jones.) 



called Nabothian follicles — are present in considerable number. 
These cysts are formed by the occlusion of the newly formed glands 
referred to in the description of the papillary erosion. They are 
filled with inspissated mucus and vary in number. There may be 
half a dozen, or the cervix may be fairly riddled with them. In 
size they vary from a B.B. shot to an English walnut in extreme 
cases. They are usually not larger than a pea. To the examining 
finger the retention cyst feels like a shot; to the eye it appears as 
a little rounded elevation of a bluish-white or yellow color. 

Diagnosis. — Leucorrhea is the constant symptom of endocervi- 
citis. The diagnosis is made by digital and speculum examinations. 
The finger detects lacerations, the soft velvety surface of the 



186 THE DIAGNOSIS OF ENDOMETRITIS 

erosion, the stringy plug of mucus in the os, shot-like retention 
cysts, and tenderness of the tissues of the cervix. The speculum 
shows the scars of the lacerations and thus their extent, the dull 
red roughened surface of the erosion, the plug of mucus in the os, 
polypi, and retention cysts, if they exist. The fact that erosions 
are found in the virgin and even in the infant (see Chapter XXVIII. , 
page 563) must be borne in mind. The determining factor in 
the causation of this condition seems to be the exposure of the 
columnar epithelium with which the canal of the cervix is lined 
to the conditions which obtain in the vagina where the mucous 
membrane is paved with squamous epithelium. 

Differential Diagnosis. — The differential diagnosis concerns itself 
with the exclusion of ulceration due to (1) an ill-fitting pessary, 
(2) to tuberculosis; (3) to chancre or chancroid, and (4) to 
carcinoma. All forms of true ulceration are rare, — erosions are 
common. 

(1) Ulceration from an Ill-fitting Pessary. — If an ill-fitting pessary 
has been removed and the ulceration does not promptly heal under 
appropriate treatment a piece of tissue should be excised under 
cocaine anesthesia and examined microscopically. 

(2) Tuberculous Ulcer. — Evidences of tuberculosis elsewhere in 
the body, a history of tuberculosis, and microscopic examination 
of the discharge and a piece of excised tissue, will establish the 
diagnosis. 

(3) (a) Chancre. — The history is an important consideration. 
A definite period of incubation of the disease is present and the 
symptomatology and signs are those of syphilis. Chancre is 
seldom seen in the initial stage, i.e., before ulceration. When 
ulcerated it is a single ulcer. The ulcer heals under antisyphilitic 
treatment. The differentiation of the Spirochsota pallida in a 
piece of tissue removed for microscopie examination makes the 
diagnosis certain. 

(b) Chancroid. — Here one finds multiple ulcers appearing soon 
after a suspicious intercourse and no symptoms of syphilis. 

(4) Carcinomatous Ulcerations. — These are generally attended 
by much thickening of the surrounding tissues and bleeding. 
A piece of tissue should be excised and sent to the pathologist for 
microscopic examination. 



CHAPTER XII 

THE DIAGNOSIS OF PELVIC INFLAMMATION 

{Pelvic Peritonitis and Pelvic Cellulitis) 

Definitions, pelvic peritonitis and pelvic cellulitis, p. 187. Routes of 
infection in pelvic inflammation, p. 187. 

Pelvic peritonitis, p. 188: Anatomy, p. 188. Etiology, p. 189. Varieties, 
p. 190; Acute pelvic peritonitis, p. 190. Chronic pelvic peritonitis, p. 191; 
Tuberculous peritonitis, p. 191. 

Pelvic cellulitis, p. 192: Anatomy, p. 192. Etiology and pathology, p. 192; 
Pelvic abscess, p. 193. Symptoms, p. 193. Diagnosis, p. 194. 

Table of differential diagnosis of pelvic inflammation, p. 195. 

Definition. — The term pelvic inflammation signifies broadly 
inflammatory action situated in any of the structures occupying 
the pelvis. It will be used in this chapter to mean inflammation 
in the peritoneum which covers the pelvic organs, and in the under- 
lying cellular connective tissue of the pelvis. 

The inflammatory process when confined to the pelvic peritoneum 
constitutes a pelvic peritonitis, and when in the pelvic cellular 
tissue a pelvic cellulitis. 

Pelvic Peritonitis. — This is a very common affection and accom- 
panies inflammatory affections of the ovaries and tubes, as well as 
inflammation of the peritoneum of the entire peritoneal cavity. 
The inflammation extends to the cellular tissue from propinquity 
and therefore the two processes are often combined. 

Pelvic Cellulitis. — This, on the other hand, is a rare affection 
following labor or abortion and exhibits less tendency to extend to 
the peritoneum and to the overlying structures. It is often im- 
possible to differentiate between the two varieties of pelvic inflam- 
mation, especially in the later stages. An attempt will be made 
to describe both forms, beginning with the more important: first, 
saying something of the routes of infection and the character of 
the structures involved. 

Routes of Infection in Pelvic Inflammation. — Infection may reach 
the pelvic peritoneum and cellular tissue (1) from (he outside, 
through the lumen of the vagina, litems, and tubes, or (2) from the 
blood current and the lymphatics. 

187 



188 THE DIAGNOSIS OF PELVIC INFLAMMATION 

1. It is possible for infection to travel through the vagina, uterus, 
and tubes without leaving traces behind it. Often, at the time the 
patient first comes under observation, the inflammatory processes 
in these structures have burned themselves out. 

2. The blood or lymph vessels may bring infection to the pelvis 
from distant organs, though this is rare. Generally the infective 
microorganism is near at hand either in the uterus, tubes, bladder, 
or rectum, rarely in an infected ovarian cyst, a suppurating appen- 
dix vermiformis, or the large or the small intestine. 

Occasionally infection comes to the pelvis in a psoas abscess or 
other abscess of distant origin, such as an abscess about the sacro- 
iliac or hip joints. The following bacteria have been found in 
cases of pelvic inflammation, generally in mixed culture, and they 
may be classed as causative of the inflammation: — 

Gonococcus. 

Colon bacillus. 

Streptococcus pyogenes. 

Staphylococcus pyogenes albus, aureus, and citreus. 

Tubercle bacillus. 

Diphtheria bacillus. 

Typhoid bacillus. 

Pneumococcus. 

Actinomyces. 

PELVIC PERITONITIS 

Anatomy 

The pelvic peritoneum covers the concave surface of the floor 
of the pelvis. Beginning on the anterior wall of the abdomen 
behind the pubes and passing downward and backward, it covers 
first the posterior surface of the bladder. In this situation it is 
loosely adherent and has more or less cellular tissue under it. 
From the bladder it reaches the uterus just below the level of the 
internal os and thence rises over the anterior aspect of the body of 
the uterus. This lowest portion forms the so-called vesico-uterine 
pouch. Passing over the fundus of the uterus, where it is closely 
adherent, the peritoneum is continued on the posterior surface 
of the body of the uterus to a point a little below the level of the 
internal os where it leaves the uterus to dip down deep in the pelvis 



PELVIC PERITONITIS 



1S9 



to form the cul-de-sac of Douglas. Its lowest point in the cul-de-sac 
varies, but averages half an inch or so below the attachment of the 
vagina to the cervix. Rising from the cul-de-sac of Douglas, the 
peritoneum reaches first the anterior part of the middle portion of 
the rectum. Higher up it reaches the sides of this viscus and still 
higher the posterior portion of the first part of the rectum. At 




Fig. 70. — Reflections of the Folds of the Peritoneum 
(Dotted Lines). 

the sides of the uterus the folds of the peritoneum form the broad 
ligaments. Above they cover the Fallopian tubes and the posterior 
surfaces of the ovaries. 



Etiology 

Pelvic peritonitis, the more common of the two sorts of pelvic 
inflammation, is almost always secondary to salpingitis. It may 
follow the escape of pus or even menstrual blood or injected fluid 
from the ostium abdominale of the Fallopian tube, or it may follow 
septic metritis, cystitis, proctitis, perforation of the uterus, appendi- 
citis, or psoas abscess. 

The gonococcus and streptococcus are, as far as we know, the 
bacteria most frequently the cause of pelvic peritonitis. 



190 THE DIAGNOSIS OF PELVIC INFLAMMATION 

Varieties 

The disease is acute or chronic. 

Acute Pelvic Peritonitis. — This is manifested by sharp pains in 
the lower abdomen and pelvis, rigidity of the abdominal muscles, 
tenderness to examination both of the abdomen and the vagina, 
fever, rapid pulse, nausea, vomiting, constipation, and nervous 
depression. 

The greater the tendency of the peritonitis to become a general 
peritonitis, the more pronounced are the symptoms. If the resist- 
ing power of the individual is great, i.e., a high opsonin index is 
present, and the virulence of the infecting bacteria little, or the 
dose small, the inflammation may subside, leaving behind it ad- 
hesions between the opposing folds of peritoneum. Thus the tubes 
become glued in the cul-de-sac frequently, and coils of intestine 
are fastened to the tubes. In the severer grades of inflammation 
the omentum helps to wall off the process from the general cavity 
of the peritoneum. It applies itself to an inflamed tube in an 
almost intelligent manner. If resolution does not occur because 
of the great virulence of the infective material or lessened resistance 
of the patient, a chronic pelvic peritonitis, or a pelvic abscess, 
results. Without treatment such a pelvic abscess most commonly 
opens into the rectum, although it may find exit into the bladder or 
through the abdominal wall. It very rarely opens into the uterus 
or vagina. 

The diagnosis is established by the presence of the symptoms 
above noted and by the physical signs, which are: — on bimanual 
examination the vagina is hot, denoting increased body tempera- 
ture; the uterus is fixed and there is a sense of resistance in the 
tissues occupying the pelvis, a board-like feeling. This induration 
of the pelvic tissues, coupled with the rigidity of the abdominal 
walls and great tenderness to light pressure, make it impossible to 
map out the contents of the pelvis with exactness. A tumor mass, 
if present, is high up in the pelvis. The uterus may or may not be 
misplaced according to the situation of the greatest amount of 
exudate. If there is an abscess present a point of softening is to 
be searched for. Abscess, however, is generally rare and, if present, 
occurs in the later stages of pelvic peritonitis. Speculum examina- 
tion aids little in the diagnosis of this affection. The uterine 



CHRONIC PELVIC PERITONITIS 191 

discharges are diminished at the onset and increased in the later 
stages. The detection of a vaginitis may show the origin of a pelvic 
peritonitis and the isolation of an infective bacterium may show its 
nature. So also, examination of the rectum or bladder, should 
symptoms point the way, may help us to find the route taken by 
the infecting agent in reaching the pelvic peritoneum. Examina- 
tion of the blood generally shows an increase in the number of white 
cells, although this is not an invariable concomitant. 

Chronic Pelvic Peritonitis. — This begins with an acute attack, 
although the symptoms may be of inconsiderable moment, so as to 
escape the patient's notice. Often there will be a history of a 
series of acute attacks separated by intervals of months or years. 
The symptoms are pain of a dull character in the pelvic region, 
backache, constipation and painful defecation, disturbance of 
bladder function, and poor health. Physical examination reveals 
a larger or smaller amount of exudate and limitations of the 
mobility of the uterus, tubes, and ovaries due to adhesions. These 
organs are apt to be displaced as well as enlarged. Tenderness in 
the chronic stage is not a prominent factor as in the acute form. 

Pelvic abscess may result in the course of a chronic pelvic peri- 
tonitis. This will be described more in detail under pelvic cellulitis, 
as it is more often found in the latter affection. 

Tuberculous Peritonitis. — Tuberculous peritonitis is one variety 
of chronic pelvic peritonitis. Here the disease, as seen clinically, 
is seldom limited to the pelvis, being an affair of the general peri- 
toneum. 

The disease begins in the Fallopian tubes in a vast majority of 
instances, and is sometimes seen and diagnosed before it has 
reached the general peritoneal cavity. It is characterized by a 
gradual onset, by fever recurring every evening and disappearing 
in the morning, rapid pulse, sweating, particularly at night, loss 
of weight, loss of strength, and anorexia. As the disease progresses 
there is enlargement of the abdomen due to the presence of plastic 
exudate or to the accumulation of fluid. Early in the disease 
nothing characteristic can be made out. An enlargement of a tube, 
with surrounding exudate, increasing in size when examined at 
repeated intervals, coupled with a family history of tuberculosis, 
previous tuberculosis in some other organ, and the symptoms just 
enumerated, make a probable diagnosis of tuberculous pelvic per- 



192 THE DIAGNOSIS OF PELVIC INFLAMMATION 

itonitis. Elimination of the other causes of salpingitis, such as 
gonorrhea, may be of assistance. The disease is found most often 
in virgins. In chronic pelvic peritonitis we do not expect to find 
leucocytosis, even if an abscess is present, although it may occur. 
Pelvic peritonitis leaves behind it many disabling lesions in the 
shape of adhesions and displacements. It is the cause of a large 
portion of the diseases peculiar to women, and therefore should 
receive most careful attention at the hands of the physician. 



PELVIC CELLULITIS 

Anatomy 

The cellular tissue of the pelvis lies under the peritoneum. In 
it pass the blood-vessels, arteries and many large veins, and 
the lymphatics. It is most abundant in the bases of the broad 
ligaments and between the peritoneum of Douglas' pouch and the 
vagina and lower rectum. Therefore, these are the situations 
where the cellulitis occurs most often. The peritoneum is pretty 
closely attached to the uterus, Fallopian tubes, and ovaries. That 
is to say, very little cellular connective tissue is present under the 
peritoneum in these regions. It is less closely attached to the 
bladder. 

Etiology and Pathology 

Pelvic cellulitis is a relatively rare affection. In more than 
two-thirds of the cases it is of puerperal origin, and is generally 
due to infection by the common pus-producing cocci which enter 
the pelvic cellular tissue from the uterus. Infection may come 
from the vagina, rectum, or bladder, or from unclean instrumenta- 
tion or septic manipulation. The trauma incident to parturition 
opens the way for the entrance of bacteria. The common situa- 
tions of the inflammation have been foreshadowed in the descrip- 
tion of the situations in the pelvis where cellular tissue is most 
abundant. The lymph vessels and veins are affected first. A 
lymphangitis or a phlebitis may be limited by the plugging of a 
vessel by a thrombus, and in such a case infection goes no farther. 

In pelvic cellulitis the infective process extends to the tissue 
about the vessels, the cellular tissue, and we have a cellulitis. 



PELVIC CELLULITIS 193 

The infective inflammation may go through all three of the initial 
stages of inflammation, i.e., congestion, effusion, and suppuration, 
or only the first, or the first two. The process, from a pathological 
point of view, is not so different from that of a furuncle, namely, 
infection conveyed into a connective-tissue area. 

Pelvic Abscess. — If the process goes on to suppuration the pus 
is evacuated in time spontaneously into the vagina or other pelvic 
viscera, often doing a good deal of damage before this issue is 
attained. Should the abscess open into the bladder or rectum, 
it is unlikely to heal and the patient becomes septic and dies from 
septicemia after a long illness. This is frequently the result even 
if most thorough drainage is made, provided intervention has 
been postponed until the abscess has burrowed extensively into 
the tissues of the pelvis and the resisting powers of the patient 
have been reduced to low limits. Early surgical intervention 
and drainage of the abscess into the vagina result in speedy heal- 
ing, just as in the case of a boil, with nothing left behind except 
malposition of the uterus, tubes, and ovaries, and rarely dislocation 
of the bladder, or stricture of the rectum or urethra. 

There is no tendency to recurrence and no chronic process as 
in the case of pelvic peritonitis, where the inflammation originates 
in the Fallopian tube, which is lined with mucous membrane. 
It is a well-known fact that infection tends to lurk in mucous 
membranes, and it does not remain in the cellular tissue. Forms 
of chronic cellulitis have been described, such as the chronic atrophic 
cellulitis of Freund, also an edematous form. It is a question, how- 
ever, whether such processes really originate in the cellular tissue. 

A pelvic abscess may result from a rupture of a pyosalpinx into 
the cellular tissue of the broad ligament or of the retro-uterine 
space. In this case one would expect that the healing process 
would be more protracted, and such is generally the case. So also 
in severe grades of cellulitis originating in the uterus, the over- 
lying tubes and ovaries become infected by extension and have 
to be reckoned with in the treatment and prognosis. 

Symptoms 

The symptoms of pelvic cellulitis -ah' (a) general, those common to 
infections, i.e., fever, rapid pulse, chills, prostration; and (b) local, 

13 



194 THE DIAGNOSIS OF PELVIC INFLAMMATION 

severe pain in the pelvis, sensitiveness to light touch, both of the 
abdomen and the vagina, also dysuria and painful defecation. The 
local symptoms abate quickly, even if the process goes on to sup- 
puration, and most rapidly if resolution occurs. 

Diagnosis 

By conjoined manipulation there is found a tumor in the pelvis 
occupying the region of the broad ligament on one side, or the 
retro-uterine space behind. The recto-abdominal touch is espe- 
cially useful in diagnosing this affection. If the mass is in the 
usual situation in the base of the broad ligament, the uterus is 
crowded to the opposite side, the tumor, which is hard or boggy 
to the feel, bulges into the vagina. If the tumor is in the retro- 
uterine space the lumen of the vagina is encroached upon and the 
bladder and cervix are crowded forward against the pubes and 
anterior abdominal wall. In the acute stage there is rigidity of the 
abdominal muscles, as well as sensitiveness, so-called peritonismus. 
This soon subsides. In the later stages when there is abscess for- 
mation it is difficult to find the situation of the uterus without 
the aid of a sound. There is a mass in the pelvis that may occupy 
nearly the entire cavity. The pus generally burrows into the 
retro-uterine space. Rectal examination will often show the 
upper limits of the tumor; combined rectal and vaginal examina- 
tion is always of value in mapping out the size and form of the 
sort of cellulitis that begins in the retro-uterine cellular space. 
In some cases there is marked edematous thickening in the space 
between the upper and middle portions of the vagina and the 
rectum. This is palpated with great exactness by one finger in 
the rectum and another in the vagina. The detection of fluctua- 
tion in a pelvic abscess in not easy because thick walls of lymph 
are effused and encompass a collection of pus of any considerable 
size. 

Often an effusion of blood in the peritoneal cavity, a pelvic 
hematocele of several weeks' standing, simulates a pelvic abscess. 
The hematocele should have a boggy feeling, not unlike feces of 
pasty consistency, but on account of the wall of organized lymph 
with which it is surrounded and the tension of the contents of the 
sac there may be no boggy feeling. The history of the beginning 



DIFFERENTIAL DIAGNOSIS OF PELVIC INFLAMMATION 195 

of the attack, if obtainable, will throw light on the diagnosis, 
hematocele being ushered in by severe pain and rectal tenesmus, 
and with prostration but no fever. Pelvic cellulitis always begins 
with fever. 

The sequelae of pelvic cellulitis are not so serious as those of 
pelvic peritonitis. Neglected cases may leave crippling traces 
because of the involvement of ovaries, tubes, rectum, ureter, or 
bladder. Cases which end in speedy resolution, either spon- 
taneously or because of prompt surgical interference, often leave 
no other traces than a cicatrix, or a small area of induration in 
the vagina. 



DIFFERENTIAL DIAGNOSIS OF PELVIC INFLAMMATION 

The following table of the differential diagnosis of pelvic inflam- 
mation has been modified from that in E. C. Dudley's " Text- 
book of Gynecology": 



Pelvic Peritonitis. 

A. Exudate surrounds uterus and is 
apt to be high in pelvis. 

B. Uterus fixed wherever it happens 
to be. 

C. Pain severe and paroxysmal in 
acute stage. 

D. Tendency to suppuration not 
marked. 

E. Frequently results in general 
peritonitis. 

F. Constitutional symptoms more 
severe. Apt to be nausea and vomit- 
ing. 



Pelvic Cellulitis. 

A. Tumor usually at one side of 
uterus and low in pelvis. 

B. Uterus displaced laterally, not 
necessarily fixed. 

C. Pain less severe and more con- 
tinuous. 

D. Tendency to suppuration marked. 

E. Seldom results in general per- 
itonitis. 

F. Constitutional symptoms less 
severe. No nausea and vomiting. 



Pelvic Peritonitis in Douglas' Cul-de-sac. 

A. Tumor mass has a sharp outline 
and is relatively hi<rh in pelvis. 

B. Uterus is displaced forward. 



Retro-uterine Cellulitis. 

A. Tumor mass of indefinite outline 

IS Situated in the space between rectum. 
vagina, and uterus in pelvie floor and 
is fl.it fcened in form. 

B. Cervix uteri alone bent forward 
or to thf side, no! the body and fundus. 



196 THE DIAGNOSIS OF PELVIC INFLAMMATION 

Pyosalpinx. Pelvic Cellulitis. 

A. Mass on one or both sides of A. Mass on one side of uterus only 
uterus and back of it, not bulging into and low in the pelvis, bulging into the 
the vagina. vagina. 

B. Mass of sharp outline and sausage- B. A diffuse swelling, 
shaped. 

C. Mass partly movable. C. Mass fixed. 



Chronic Pelvic Hematocele. 

A. History of tubal pregnancy with 
symptoms of sudden internal hemor- 
rhage. May be repeated light attacks. 

B. No chill or fever. 

C. Relatively rapid increase in size 
of tumor. 

D. Tumor doughy and elastic. 

Appendicitis with Abscess. 

A. Onset with severe symptoms and 
nausea and vomiting. 

B. Tenderness over appendix region. 

C. Exudate high up in pelvis. 
Reached by vaginal or rectal examina- 
tion only with difficulty. 



Psoas A 

A. History and symptoms of tuber- 
culosis. 

B. Evidences of Pott's disease. 

C. No history of acute onset. 

D. Limitation of motion and pain in 
thigh. 

Subserous Myoma. 

A. No history of infection. 

B. No history of acute onset. 

C. Contour of the tumor rounded, 
sharply defined, and tumor intimately 
connected with the uterus. 



Pelvic Cellulitis. 
A. History of infection. 



B. Chills and fever. 

C. Slow development of tumor. 

D. Tumor hard until suppuration. 

Pelvic Cellulitis (Right Side). 

A. Onset with less severe symptoms; 
no nausea and vomiting. 

B. No tenderness over appendix 
region. 

C. Exudate low in pelvis in base of 
broad ligament or in retro-uterine space. 
Easily palpated through vagina and 
rectum. 

Pelvic Cellulitis. 

A. History of non-tuberculous in- 
fection. 

B. No evidences of Pott's disease. 

C. History of acute onset. 

D. No limitation of motion or pain 
in thigh. 

Pelvic Cellulitis. 

A. History of infection. 

B. History of acute onset. 

C. Tumor of indefinite outline and 
not so intimately connected with the 
uterus. 



CHAPTER XIII 

THE DIAGNOSIS OF CONGENITAL ANOMALIES OF THE 

UTERUS, LACERATION OF THE CERVIX UTERI, AND 

DISEASES OF THE UTERINE LIGAMENTS 

Diagnosis of congenital anomalies of the uterus, p. 197: I. Anomalies due 
to arrest of development, p. 198 : Absence of the uterus, p. 198; Rudimentary 
uterus, p. 198; Uterus bipartitus, p. 200; Uterus didelphvs, p. 200; Uterus 
bicornis, p. 200; Uterus septus, p. 200; Uterus unicornis, p. 200; Diagnosis, 
p. 201 ; Differential diagnosis, p. 202. II. Anomalies due to arrest of growth, 
p. 202: Infantile uterus, p. 202; Congenital atrophy, p. 203; Puerperal 
atrophy, p. 203; Non-puerperal atrophy, p. 203. 

Diagnosis of laceration of the cervix uteri, p. 204: Anatomy, p. 204. 
Etiology, p. 204. Mechanism and pathology, p. 205. Results of laceration, 
p. 206: Subinvolution, p. 207; Diagnosis of laceration, p. 208: Recent 
lacerations, p. 208; Old lacerations, p. 209. Differential diagnosis, p. 210. 

Diagnosis of the diseases of the uterine ligaments, p. 210 : The broad 
ligaments, p. 211 : Parovarian cysts, p. 211; Varicocele of the broad ligament, 
p. 212. The round ligaments, p. 212: Tumors, p. 212; Hydrocele of the 
canal of Nuck, p. 213. The utero-sacral ligaments, p. 213. The utero- 
ovarian ligaments, p. 214. 

Certain points in the anatomy and mechanics of the uterus have 
been considered in Chapter V., page 44, and others will be 
described in Chapter XIV., on the diagnosis of malpositions of the 
uterus, pages 222-224. The endometrium has been described in 
Chapter XL on Endometritis, page 166. In the present chapter we 
will take up the arrests of development, lacerations of the 1 cervix, 
and diseases of the uterine ligaments. 



DIAGNOSIS OF CONGENITAL ANOMALIES OF THE UTERUS 

The uterus, which in the virgin measures three inches in length, 
two inches in breadth at the fundus, and nearly an inch in thickness, 

is developed from the coalescence of the two Miillerian ducts in 
the embryo. This coalescence takes place from the eighth to 
the twelfth weeks of fetal life. The development should be com- 
plete, with the septum between the two ducts absorbed and the 

197 



198 



CONGENITAL ANOMALIES OF THE UTERUS 



uterus completely formed, by the twentieth week, and after this 
time the question is one of growth, and not of development. The 
period of growth extends to the twentieth year of life. Therefore, 
in seeking the cause of uterine anomalies we have to consider two 
factors — arrested development and arrested growth. 






%■ Ostium aS^ominah 



Ovary--- 
Epoophoron 



x v 



rfuJkrmrj Jucr^~ ----- 
tubal portion. 



3iadder— 



*"1 




Ureter- - 



Urethra- 



Wolffian 
JJ duct 



-f Mullen an duck 

( Ufen'nC porttoq. 



L ^fuller tar} ducts 

J Vaginal portion 

/ 
Urogenital £mu$. 



Fig. 71. — The Development of the Tubes. Uterus and Vagina in the Fetus. 
The Vaginal Portions of the Miillerian Ducts Are Here Still Separate. (After 
J. Kollmann.) 



I. Anomalies due to Arrest of Development 

Absence of the Uterus. — Complete absence of the uterus, i.e., 
those cases in which there is present not even a knob of tissue at 
the upper end of the vagina to represent a uterus, is an affair only 
of non-viable fetal monstrosities or pseudo-hermaphrodites. 

Rudimentary Uterus. — Rudimentary uterus, on the other hand, 



ANOMALIES DUE TO ARREST OF DEVELOPMENT 



199 



is not so uncommon. A goodly number of cases have been re- 
ported in the literature and they generally appear under the caption 
of "absence of the uterus" because the diagnosis is so difficult 
during life. In these cases there is present, in the situation usually 
occupied by the uterus, a knob of connective tissue of variable 





Fig. 72. — Uterus Bipartitus. 



Fig. 73.— Uterus Didelphys. 





Fig. 74. — Uterus Bicornis. 



Fig.. 75. — Uterus Septus. 





Fig. 76. — Uterus Unicornis. 



Fig. 77. — Uterus Unicornis with 
Accessory Cornu. 



size and there is partial or complete absence of the vagina. The 
tubes are absent and the ovaries may or may not be absent. If 
they are present the patient suffers from molimina. Patients with 
this abnormality of development are generally well-formed women 
with normal external genitals, breasts, hair, and voice, who consult 



200 CONGENITAL ANOMALIES OF THE UTERUS 

the physician because of the absence of menstruation. The case 
of a married woman reported by me,— "Congenital Absence of 
Uterus and Vagina " (Amer. Jour, of Med. Sci., March, 1897), 
came under observation because of the absence of a vagina. 

The diagnosis is made by recto-abdominal examination with the 
patient under an anesthetic, — also by examination with a large 
sound in the bladder and the finger in the rectum. An absolute 
diagnosis can be made only by an abdominal section or by a post- 
mortem examination. 

Uterus Bipartitus. — Uterus bipartitus consists of a poorly de- 
veloped cervix continuous with two rudimentary united cornua 
which are usually solid cords, but may be provided with, pervious 
canals as in the figure. The ovaries are generally present in an 
undeveloped state. Here only the lower part of Muller's ducts 
have succeeded in coalescing to form a cervix, failing to unite in 
their upper portions. 

Uterus Didelphys. — This is rare. It consists of two separate 
uteri, each with one horn, and two separate vaginae. Sometimes 
the lower extremity of one vagina is occluded at some point above 
the vulva and may contain retained secretions. (See Congenital 
atresia of the vagina, Chapter XX., page 357.) 

Uterus Bicornis. — Uterus bicornis is a relatively common condi- 
tion. In it Muller's ducts have united to form a cervix with two 
canals and two ora, but are ununited above, so that there are two 
long cornua representing a uterine body. Sometimes the union 
has progressed to a point a little higher up in the cervix and we 
have one external os and one cervical canal below, and two cer- 
vical canals above, or the condition known as Uterus bicornis uni- 
collis. (See Fig. 78.) 

Uterus Septus. — Uterus septus is the coalescence of the ducts 
to form a uterus which appears to be normal externally but within, 
its cavity is divided longitudinally into two cavities by a persist- 
ence of the septum. 

Uterus Unicornis. — Uterus unicornis results from the develop- 
ment of only one cornu, the other being entirely absent or rudi- 
mentary. The corresponding Fallopian tube is generally absent. 
If secretions accumulate in the rudimentary cornu, there being no 
outlet, a distended sac will be formed; but fortunately this is a 
rare happening. Pregnancy may occur in a rudimentary horn, 



ANOMALIES DUE TO ARREST OF DEVELOPMENT 



201 



also in uterus didelphys, and, of course, in uterus septus. (See 
Chapter XXII., page 433.) 

Diagnosis of Uterine Anomalies Due to Arrest of Development. — 

The diagnosis of uterine anomalies due to arrest of development 
rests on the symptoms in the rare eases where accumulation of 
secretions forms a sac that presses on the bladder or rectum, or 
causes cramps; or cases in which menstruation does not occur at 
the normal age. As regards the latter it should be remembered 
that menstrual blood may flow from one half of a uterus while it is 
collecting in the other half. Abortion and premature labor are 
more frequent in the case of double uterus, and the presence of a 
septum makes deliver}' difficult and involution slower. A decidua 



fwroicj nodules 




of cervi* w,/'. 



Fig. 78. — Bicornute Uterus, One External ( K Two Uterine Cavities. Removed 
from Single Woman 31 Years old, Jan. 27, 1903, for Rebellious Dysmenorrhea. 



forms in the empty half of a septate pregnant uterus or in a rudi- 
mentary horn just as it forms in the uterus in the case of tubal 
pregnancy. 

By examination the presence of two vaginal canals is a definite 
indication of a double uterus. If the vagina is single the two ora 
of a didelphys uterus may be palpated by the examining finger 
and may be seen through the speculum. Two uterine horns, or a 
divided fundus, may be felt by bimanual examination if the 
conditions are exceptionally favorable, that is, a thin and lax 
abdominal wall and absence of much fat. If the uterus feels 
normal to the bimanual palpation except for the presence of two 
ora in the cervix, two sounds arc passed simultaneously, one into 
each os, and an attempt made to make them meet in the uterus. 



202 CONGENITAL ANOMALIES OF THE UTERUS 

If they do not meet, the case is one of uterus septus. If the sep- 
tum does not reach to the external os the diagnosis is more diffi- 
cult, and in this case the lower edge of the septum may possibly 
be felt with the tip of the sound. If the bimanual touch shows 
that there is a depression in the fundus we have to do with a case 
of uterus didelphys or uterus bicornis, the latter being much more 
frequent. The halves of a uterus bicornis are commonly closely 
adherent well above the level of the internal os and can not be 
moved independently, whereas in the case of uterus didelphys 
the two halves are well separated and can be so moved. They 
may lie even at some distance from each other, and the point of 
separation may be felt by rectal palpation, and if the conditions 
for palpation are favorable, an ovary attached to each horn may be 
palpated. 

The diagnosis of the one-horned uterus is not easy. The fundus 
is found to one side of the pelvis, it is tapering, and only one ovary 
can be made out. Hematometra or pyometra may be present, 
and are to be diagnosed as swellings occupying a portion of the 
uterus. The diagnosis is difficult and is seldom made exactly 
without opening the abdomen. 

Differential Diagnosis. — It is important to distinguish pregnancy 
in a detached cornu of an anomalous uterus from a fibroid tumor. 
The occurrence of irregular hemorrhage from the uterus and the 
absence of the signs and symptoms of pregnancy, together with 
hardness and irregularity of the surface of the tumor, serve to 
point toward a fibroid. 

II. Anomalies Due to Arrest of Growth 

These are infantile or "puerile uterus, in which the uterus of the 
adult remains of the type found at birth, — and congenital atrophy 
of the uterus, in which the organ, though of the type of the adult, 
is atrophied as a whole. These two sorts of malformations are 
not very uncommon. The condition known as retroposition with 
anteflexion (see page 231) would seem to be closely allied to the 
infantile uterus. 

Infantile Uterus. — This is a relatively common condition. The 
infantile uterus is narrow in proportion to its length, has a long 
cervix and a short body, and the uterus is situated well back and 



ANOMALIES DUE TO ARREST OF GROWTH 203 

high in the pelvis at the end of a long vagina, there being at the 
same time more or less anteflexion. The os is a ''pinhole os" and 
the cervix is conical. Menstruation is usually absent in these cases, 
but the breasts, figure, hair, and voice may be perfectly normal; 
sexual desire is absent and the patient is necessarily sterile. The 
diagnosis is made by the bimanual recto-abdominal touch and by 
passing the sound. The situation of the internal os, where the tip 
of the sound or probe catches, is well up in the total length of the 
uterus and is characteristic, and the relatively large and long 
cervix, and short and slender body, can be made out easily. The 
ovaries are apt to be small in these cases. Help in the diagnosis 
is obtained often if the uterus is drawn down by a tenaculum held 
by an assistant while the bimanual touch is practiced. 

Congenital Atrophy. — The congenital atrophic uterus is a rare 
condition. Here the diagnosis is made by finding a well-propor- 
tioned uterus which is small in all of its diameters. This anomaly 
is associated with lack of body growth, absence of pubic hair and 
sex characteristics. We must suppose that the individual attained 
a proper growth of the uterus to the virgin type followed b} T atrophy. 
The condition has been found in dwarfs and cretins and in cases of 
early tuberculosis and chlorosis. 

Puerperal Atrophy. — The opposite of subinvolution is puerperal 
atrophy, superin volution. Vineberg of New York has added to 
our knowledge of lactation atrophy. (Amer. Medico-Surg. Bull., 
N. Y., 1895, VIII., 1518.) It is a shrinking of the uterus in size 
symmetrically below the virgin type, following prolonged lactation, 
and is due probably to overstimulation of the uterus due to nursing. 
It is not a permanent condition, the uterus returning to its normal 
size two or three months after nursing has been discontinued. It 
would appear that a certain amount of atrophy is normal during 
the puerperium irrespective of lactation, therefore superinvolution 
is a distinctly pathological stale 

Non-puerperal Atrophy. — This occurs even more rarely than 
puerperal atrophy, in chronic wasting dig is in tuberculosis, 

and in the acute 4 infectious diseases, such as scarlatina. I have 
Been one case following steaming of the uterine cavity. Non- 
puerperal atrophy may or may not be permanent. The exact 
causes are not known. 



204 LACERATION OF THE CERVIX UTERI 



DIAGNOSIS OF LACERATION OF THE CERVIX UTERI 

The credit for a proper understanding of laceration of the cervix 
uteri is due to Thomas Addis Emmet, of New York, who published 
his first paper on the subject, " Surgery of the Cervix Uteri," in the 
American Journal of Obstetrics in February, 1869. Previous to 
this the effects of lacerations were treated under the name of 
ulcerations of the womb, coxcomb granulations, or erosions of 
various sorts. 

In a large proportion of cases the cervix is torn during labor, 
the few cases where it is injured by forcible dilatation or incision 
at the hands of the physician being disregarded here, although it 
happens not at all infrequently that the upper portion of the cervix 
is injured by the two-branched steel dilators employed in dilata- 
tion for curetting. 

Anatomy 

The normal cervix in the virgin is slightly conical and projects 
into the vagina from a half to five-eighths of an inch (1 to 1.5 centi- 
meters). The os is round or oval in shape and about a sixteenth 
of an inch in diameter. In women who have borne children the 
os is more of a transverse slit (see Figs. 65 and 66) and may be 
irregular from lacerations, and the cervix is rounder and less conical 
than in the virgin. To the feel the tissues are firm, but not hard, 
and seen through the speculum are of a yellowish pink color. 
The wall of the cervical canal presents anteriorly and posteriorly 
a longitudinal column from which proceed a number of oblique 
columns, giving the appearance of branches from the stem of a tree. 
This is called the uterine arbor vitce. These columns become more 
indistinct after the first labor, but they are not obliterated. 

Etiology 

The causes of laceration may be enumerated as: (1) A rapid 
second stage of labor, (2) A large child and a small cervix, (3) A 
rigid cervix, as in abortion, or from diminished elasticity of the 
tissues,, (4) Instrumentation, as from the forceps or instruments 
used in embryotomy, or in dilatation, (5) Friability of the tissues of 



MECHANISM AXD PATHOLOGY 



205 



the cervix due to prolonged pressure by the presenting part, or 
to disease of the cervix. 

Mechanism axd Pathology 




In the virgin uterus the canal of the cervix at its widest part, 
i.e., midway between the external os and the internal os, is about 
one-fifth of an inch in diameter. During delivery this must be 
dilated to the diameter of the child's head, some four and a half 
inches. The muscular fibers of the cervix become stretched ex- 
cessively and it is not surprising that lacerations occur, especially 
if insufficient time is given 
for the dilatation. Lacera- 
tions may occur in any di- 
rection or in several direc- 
tions, that is, they may be 
unilateral, bilateral, or stel- 
late, and anterior or poster- 
ior. They are most often 
lateral. Extensive tears 
which involve the cervix 
above the attachment of the 
vagina are apt to result in 
infection of the perimetric 
tissue (cellulitis). During 

pregnancy the cervix together with the rest of the uterus is enlarged 
to accommodate the growing fetus, The rhythmical contractions of 
the uterus during the entire pregnancy reach their climax in labor 
when the major part of the hypertrophied uterine muscle acts as 
an expellent force, while the small portion of the uterus, the lower 
part of the cervix, acts a passive r61e and is dilated. This lower 
part of the cervix may be likened to the sphincter ani muscle. 
After receiving an excessive stretching as a preliminary to an oper- 
ation for hemorrhoids, or other operation on the rectum, the 
sphincter ani does not recover its tone and is unable to contract 
for forty-eight hours, more or less in fad it has been stretched for 
this very purpose. So in the case of the lower cervix after labor. 
It is a flabby, soft ring that has no power of contracting. Under 
normal conditions, and when not lacerated, it contracts to the 



Fig. 79.- 



Bilateral Lacerations of the Cer- 
vix with Erosions. 



206 



LACERATION OF THE CERVIX UTERI 



dimensions of a parous, normal cervix in the course of a few days. 
When torn the lips are turned out into the vagina by the weight 
of the large uterus above and the contracting power of the cervix 
is thus lost. (See Fig. 82.) The intracervical tissues are everted 
into the vagina, the uterine circulation is interfered with, the tissues 
become engorged and remain swollen — therefore there is no longer 
room for them within the uterine canal. Infection of the rolled-out 
mucosa adds to the trouble and erosions, endometritis and cystic 
degeneration result, with ultimate thickening of the torn lips from 
subinvolution. Because of the downward excursion of the heavy 

uterus the cervix projects 
relatively farther into the 
vagina and the attachments 
of the latter organ to the 
cervix appear to be higher 
up on the uterus, although 
in reality they are not, and 
thus the torn cervix seems 
to be larger than it is. Sub- 
involution, or chronic me- 
tritis, keeps the uterus heavy 
and in this manner accent- 
uates the eversion. Lacer- 
ations of not great extent 
unite readily in the absence of infection. If pelvic inflammation 
is present lacerations are apt not to heal so soon, if at all, and 
extensive lacerations may involve the vagina and even the bladder 
or rectum, leaving fistulse behind them. It often happens that 
the laceration is in the canal of the cervix and that the external 
os is little, if at all, involved. 




Fig. 80. — Stellate Lacerations of the Cervix. 



Results of Laceration 



The immediate results of laceration of the cervix are hemorrhage, 
or the production of a fistula. The later results are endome- 
tritis, subinvolution of the uterus, cystic degeneration and ero- 
sion of the cervix (see Chapter XL on endometritis, page 184), 
thus furnishing a favorable soil for the growth of cancer, cellulitis 



RESULTS OF LACERATION 



207 




(see Chapter XII. on pelvic inflammation, page 192) , cicatricial 
stenosis of the uterine canal, and a tendency to sterility and 
abortion. As regards the last, Dr. Emmet's tables (''Principles 
and Practice of Gynecology," 3rd edition, pages 447, 448) show- 
that following lacerations of the cervix 71.34 per cent of his 164 
cases were sterile, and of the 47 who became pregnant, 51 per 
cent aborted one or more times. These were in the preaseptic 
days and infection as a sequence 
to injury was undoubtedly more 
frequent than now. 

Endometritis is considered in 
Chapter XI., page 165. 

Subinvolution.— This may be de- 
fined as a failure of the physio- 
logical hypertrophy of pregnancy 
to subside after labor. It is due 
not only to laceration of the cervix 
but to malposition of the uterus 
from weakening of the uterine 
ligaments and too long a stay in 
bed, with general debility follow- 
ing confinement. After the early stages of subinvolution infec- 
tion plays a role in most cases and there is present an interstitial 
metritis, formerly called areolar hyperplasia. In this disease the 
connective-tissue elements in the uterine wall are increased and 
the muscular elements diminished. In the acute stages there is a 
round-celled infiltration; the uterus is large and feels softer. In 
the later stages the uterus is large but the tissues are indurated. 
This is the time when the connective-tissue elements predominate 
and a pathological involution takes place. The lymph and blood 
vessels are diminished in size, crowded out by the connective tissue; 
the muscle atrophies and the uterine tissues become pale and in- 
durated. Such a state of affairs is found in uteri which have 
been many years the seat of chronic met litis, not in recenl c 
i.e., generally not before four or five years after the receipt of 
injury or misplacement. Subinvolution or chronic metritis may be 
associated with arterio-sclerosis of the uterine vessels in the later 
years of life. 



Fig. 81. 



Crescentic Lacerations of 
the Cervix. 



208 



LACERATIONS OF THE CERVIX UTERI 



Diagnosis of Laceration 



The symptoms of laceration of the cervix are the symptoms of 
the pathological conditions resulting from this lesion. Immediate 
hemorrhage following labor calls for prompt diagnosis. The 
specific nervous symptoms, such as pain in the suboccipital region, 
headaches of the vertex and neuralgia, considered by Dr. Emmet 
to be due to a "cicatricial plug" in the angle between the lips of 
old tears of the cervix, are now generally thought by the profession 

to be due to a deterioration of the 
nervous system caused by pelvic 
disease in general. 

The diagnosis of lacerations is not 
an easy matter, as becomes evident 
when we reflect that the diagnosis was 
not made until Emmet showed the 
way in 1862. The results of lacera- 
tions so obscure the landmarks that 
at the time when most lacerations 
come under the physician's observa- 
tion — several years after their receipt 
— he is at a loss to determine the exact 
situation and extent of the injury. 
(a) Recent Lacerations. — In the case 
of recent tears of the cervix the only 
bars to an exact diagnosis are the 
tumefaction of the parts and the exhausted condition of the 
patient. If there is excessive hemorrhage following delivery the 
diagnosis must be made at once. In other cases it may be made 
in a few hours or days, depending on the patient's condition. The 
woman should be in the dorsal position on a table in a good 
light. The perineum being retracted by a large Sims speculum 
in the hands of an assistant, the cervix is seized with a double 
tenaculum and drawn down and search is made for solution in 
continuity in the circle of the enlarged os. Tears can be repaired 
at this time by suturing. Some operators prefer to do this in 
an intermediate time, i.e., four or five days after labor, perhaps 
scraping the edges of the tear with sterile gauze before uniting 




Fig. 82. — Diagram Showing 
Bilateral Laceration of the Cer- 
vix with Eversion of the Lips. 



DIAGNOSIS OF LACERATIOX 



209 



them. The injuries must be followed carefully to their limits, 
whether they be confined to the cervix, or if they extend to the 
vagina, or even to the rectum or the bladder. 

(b) Old Lacerations. — If every woman were submitted to a 
careful uterine examination after child-bearing, and injuries of the 
cervix, as well as those of the pelvic floor, found and repaired, there 
would be comparatively little for the gynecologist to do. It hap- 
pens, however, that most of the lacerations of the cervix come 
under the physician's notice for the 
first time some years after their re- 
ceipt. At this time the diagnosis is 
difficult because of enlargement and 
distortion of the cervix, eversion of 
the lips, and cystic degeneration of 
the Nabothian follicles and erosion. 
The trained vaginal touch after a little 
practice detects all of these features 
even to the erosion. For inspection 
the Sims position is best. Search first 
for the arbor vitse and thus deter- 
mine the situation of the cervical 
canal. The passage of the sound 
helps to define the situation of this 
canal, but the physician must be on 

his guard not to be misled by the tions of the Cervix, Producing 

malpositions of the uterus found in Obliquity of the Long Axis of the 

1 , Uterus. (After Emmet.) The 

cases of unilateral tear as pointed Reduplication of the Vagina is 
out by Emmet. (See Fig. 83.) In shown at W. 
this event the sound passed to the 

cornu opposite to the seat of the laceration may appear to be in 
the canal (see figure), but because of the tilting of the fundus 
toward the laceration the sound occupies the laceration and not 
the normal cervical canal. Here a search for the arbor vitae will 
help to set us right and the bimanual touch will also assist. 
Putting the patient in the knee-cheM position, thus permitting 
the uterus to fall toward the abdomen high in the pelvis. <t raightens 
its axis and also pulls out the reduplication of the vagina on the 
side where the laceration is situated. In all lacerations of severe 
grade it is well to study the condition- as seen through the specu- 

14 




Fig. 83. — Unilateral Lacera- 



210 DISEASES OF THE UTERINE LIGAMENTS 

lum when the patient is in this position, because in the dorsal 
position the weight of the uterus — usually increased in cases of 
laceration — drives this organ downward so that the intravaginal 
portion of the cervix seems to be longer, especially if the upper 
vagina has become stretched. Therefore, there is present in ex- 
tensive lacerations of the cervix apparent hypertrophy and elon- 
gation of the cervix beyond what really exists. This reduplication 
of the vagina is shown at X in the figure. Next, with the 
patient in the Sims position, hook a tenaculum into the crown of 
each lip of the cervix and bringing the two tenacula together, 
try to reconstruct the cervix. If there is much induration of the 
tissues this feat is difficult of accomplishment. By palpation with 
the tip of the finger or the sound, determine the situation and extent 
of cicatricial tissue in the angle of the tear, pressure on the tissue 
causing pain. With the tip of the sound a laceration within the 
canal of the cervix may be appreciated, for in that situation the 
sound falls into an opening in the otherwise smooth mucosa of 
the wall of the canal. The internal os will be found abnormally 
large should the laceration involve this region, permitting the sound 
to be moved freely about after it has been passed through. 
When the arbor vitse has been made out the situation of the 
laceration with reference to it is determined. 

Differential Diagnosis of Lacerations 

Cancer of the cervix is the disease most often mistaken for lacer- 
ated cervix. The differential diagnosis is considered under cancer 
of the cervix, Chapter XVI, page 272. Carcinoma is attended by 
much induration of the tissues and ulceration, also cancer bleeds 
easily and the superficial portions are friable. Endocervicitis and 
erosion is a coincident condition in laceration, but may exist in 
the absence of laceration. The diagnosis is based on the absence 
of the signs of laceration. Eversion of the mucous membrane of 
the cervical canal may be present without laceration and it is well 
to bear this fact in mind. The cervix in such cases is of normal 
contour and there are no evidences of laceration. 

DIAGNOSIS OF DISEASES OF THE UTERINE LIGAMENTS 

The uterine ligaments are the broad ligaments, the round liga- 
ments, the utero-sacral ligaments, and the utero-ovarian ligaments. 



THE BROAD LIGAMENTS 211 



The Bkoad Ligaments 



These become stretched in prolapse of the uterus so that they no 
longer support that organ. Under normal conditions they have 
enough elasticity, together with the utero-sacral ligaments, to re- 
store the uterus to its normal situation after it has been drawn 
down forcibly. Certain tumors originate in the broad ligaments, 
notably parovarian cysts, fibromata and lipomata, also dilatation 
of the veins, varicocele. The solid tumors are extremely rare, 
lipomata are seldom seen, and fibromata only occasionally, the lat- 
ter being not large as a rule and arising in the unstriped muscle fiber 
between the folds of the ligament. Sarcoma and carcinoma of the 
broad ligament are secondary to malignant disease of the uterus. 

Parovarian Cysts. — These originate in Gartner's duct, Kobelt's 
tubules, or in the parovarium proper. Small pedunculated cysts 
may develop from one of these structures, or the cysts may be 
sessile and large. These large cysts, so called, develop between the 
layers of the broad ligament and are of slow growth. They are 
seldom larger than a child's head. The cyst has no pedicle, the 
Fallopian tube is stretched over its surface, and the cyst pushes the 
uterus to the opposite side of the pelvis. Adhesions are rare be- 
cause the cyst is covered by peritoneum. The wall of the cyst is 
thin, transparent, and of a greenish-yellow hue, the contents are a 
thin, colorless fluid of a non-irritating character having a specific 
gravity of 1002 to 1008. Upon rupture the cyst is apt not to refill, 
in this respect differing from an ovarian cyst. A parovarian cyst 
may be rarely the seat of papilloma and in this case the contents 
are opaque, the walls are thick, and the cyst is like a papillomatous 
cystoma of the ovary. The diagnosis is made by vagino-abdominal 
and recto-abdominal palpation, if necessary having the uterus 
drawn down by a vulsellum while the palpation is being practiced. 
(See Fig. 125, page 294.) The cyst is on one side of the pelvis, in 
close relation with the uterus. Its mobility is distinctly limited; 
it is ovoid in shape and has smooth walls; fluctuation is distinct, 
being felt through the vault of the vagina; there is no pedicle, but 
a groove between the cysl and the uterus can be distinguished. 
The differential diagnosis is considered in Chapter XVII, on 
ovarian tumors, page 297. 



212 DISEASES OF THE UTERINE LIGAMENTS 

Varicocele of the Broad Ligament. — This is not a very rare disease. 
It consists of dilated veins running transversely in the upper part 
of the broad ligament and forming a tumor that may be as large as 
a small hen's egg, though generally much smaller. Varicocele is 
found more often on the left side. Perhaps this is because the left 
ovarian vein is valveless and opens into the renal vein at a right 
angle. It is possible to make a diagnosis by recto-abdominal palpa- 
tion by finding a doughy-feeling tumor in the broad ligament, but as 
such a tumor is not tense except when the patient is in the erect 
posture, the diagnostician would be likely to miss it during the 
usual examination made with the patient in the dorsal position. 
If there are varicosities elsewhere in the body varicocele of the 
broad ligament should come into the physician's mind and he 
should examine the patient in the standing position. The char- 
acteristic symptom of varicocele of the broad ligament is a dull 
aching pain in the pelvis or back. 

The Round Ligaments 

The round ligaments vary much in size and in length in different 
individuals, therefore their ability to steady the uterus as guys is a 
variable quantity. The muscular fibers are situated in the inner 
two-thirds of the ligament and sometimes the ligaments are nothing 
but the slenderest of cords. Fibroma, fibromyoma, adenomyoma, 
fibromyxoma, and sarcoma of the round ligament have been de- 
scribed. The tumor is generally unilateral but may be bilateral. 
These tumors are thought by some writers to be associated with 
fibroids of the uterus. They may be found in any portion of the 
course of the ligament, — in the abdominal cavity, the inguinal 
canal, or in the labium majus, — and they develop slowly, but may 
be stimulated to more rapid growth by the presence of pregnancy. 
The tumors are hard and generally pedunculated. 

Diagnosis of Tumors of the Round Ligament. — If a tumor is situ- 
ated within the peritoneal cavity it is felt by bimanual palpation 
in the front of the pelvis on one side. If it is in the inguinal canal 
or labium majus the tumor is felt from the outside in the course of 
the canal or in the labium. It must be differentiated from omental 
or ovarian hernia, hydrocele of the round ligament, a cyst of Bar- 
tholin's gland, or enlarged inguinal lymphatic glands. There is no 



THE UTERO-SACRAL LIGAMENTS 213 

impulse on coughing or straining and the enlargement can not be 
reduced by taxis. An ovary in the inguinal canal is very sensitive 
to pressure, and swells and is painful at the time of menstruation. 
A cyst of Bartholin's gland will present fluctuation, and enlarged 
inguinal glands are generally separate glands, i.e., they are multiple 
tumors and are situated to the outside of the inguinal canal. 

Hydrocele of the Round Ligament or of the Canal of Nuck.— In the 
fetus the peritoneal covering of the round ligament projects as a 
tubular process into the inguinal canal. This tube is called the 
Canal of Nuck and it sometimes persists through life. If fluid 
collects in this canal and the abdominal end of the canal is oblit- 
erated there is found a cystic, translucent, oval tumor which may 
extend downward even into the labium majus. In size the tumor 
may be as large as a hazelnut or even attain the proportions of a 
cocoanut. It can not be pushed up into the abdomen, it fluctuates, 
and has an impulse on coughing if situated in the inguinal canal. 
In rare cases the cystic tumor may communicate with the peri- 
toneal cavity and in this event the fluid may be forced out of it by 
gentle pressure. Hydrocele is not tender like an ovarian hernia; 
it is of gradual development and often there is difficulty in distin- 
guishing a hydrocele from hernia. In the case of encysted hydro- 
cele the elastic, translucent character of the tumor that can not 
be reduced with the patient recumbent, serves to distinguish it. 
The hydrocele that connects with the peritoneal cavity can not be 
differentiated from hernia without an operation. In the case of an 
inflamed hydrocele the differentiation from a strangulated hernia 
is made by the absence of severe constitutional symptoms, and 
of symptoms of intestinal obstruction. As a matter of fact such 
tumors have generally been operated on for strangulated hernia. 

The Utero-sacral Ligaments 

The utero-sacral ligaments contain, besides connective tissue 
and peritoneum, as do the round ligaments, a certain amount 
of muscle fibers. When the uterus is drawn down forcibly there 
is elasticity enough in the ligaments to pull the uterus back again. 
The ligaments are much overstretched in prolapse of the uterus 
and are abnormally short in ret imposition with anteflexion, in the 
latter case being almost of a cicatricial hardness. Naturally liga- 



214 DISEASES OF THE UTERINE LIGAMENTS 

merits of this character limit the downward or forward excursion 
of the uterus. The diagnosis of shortening is made by the bi- 
manual vagino-abdominal and recto-abdominal touch. The uterus 
is raised and at the same time the ligaments are palpated to detect 
shortening and thickening, or the uterus is brought down by trac- 
tion with a tenaculum while the rectal touch is practiced. Short- 
ened ligaments are easier to make out than lengthened ones. In 
the infant, the uterus being very high in the pelvis, the utero- 
sacral ligaments course from their origins at the second piece of 
the sacrum to their insertions on the uterus in the form of an arch 
and may be felt in this shape by rectal palpation. The operator 
should not lose the opportunity afforded, during abdominal opera- 
tions when the cul-de-sac of Douglas is in view, to inspect as well 
as to palpate these ligaments from above. 

The Uteroovarian Ligaments 

The following tumors have been found in these ligaments: 
fibroma, sarcoma, and carcinoma. The last two must be regarded 
as extensions of the disease from the uterus; the former, fibroma, 
is very rare. These tumors can not be distinguished from ovarian 
tumors without opening the abdomen. In some cases the ovarian 
ligaments are very long, thus favoring prolapse of the ovaries. 



CHAPTER XIV 

THE DIAGNOSIS OF MALPOSITIONS OF THE UTERUS 

General considerations, p. 215. 

I. Malpositions of the uterus as a whole, p. 218: 1. Ascent, p. 218. 2. 
Descent (prolapse), p. 218; Pathology, p. 218; Mechanism, p. 219; Symp- 
toms and course, p. 226; Diagnosis, p. 226; Differential diagnosis, p. 228. 
3. Anteroposition, p. 229. 4. Lateroposition, p. 229. 5. Retroposition, 
p. 230: Retroposition with anteflexion, p. 231; Diagnosis of retroposition 
with anteflexion, p. 232. 6. Hernia of the uterus, p. 233. 

II. Abnormalities of the axis and form of the uterus, p. 234: 1. Retro- 
version, p. 234: Retro versio-flexion, p. 234; Diagnosis of retro versio-flexion, 
p. 236. 2. Anteversion, p. 238. 3. Anteflexion, p. 240. 4. Inversion, p. 
240; Diagnosis, p. 240; Differential diagnosis, p. 240. 5. Torsion, p. 243. 



GENERAL CONSIDERATIONS 

In considering the subject of malpositions of the uterus it must 
be understood that displacement of the uterus carries with it more 
or less change in the position of other pelvic organs at the same 
time. For instance, it is manifestly impossible to place the uterus 
in a condition of complete 4 prolapse without altering the position 
of the tubes, ovaries, bladder, and vagina. 

We shall consider in each instance the dislocation of the mosl 
important organ, noting the complications. The normal position 
of the uterus and the factors which determine its situation in the 
pelvis and limit its mobility under the varying conditions of health 
have been described in Chapter V., page 43. 

When pregnant or under conditions of disease the uterus is sub- 
ject to certain displacements as a whole, and its long axis may be 
turned or verted in one of several directions. Theoretically we 
have to do with two distinct classes of displacements. The uterus 
may be likened to a telescope upon a stand in a room. The tele- 
scope may be in the middle of the room (the pelvis), or it may be 
placed against the wall (retro-position), or it may be raised (ascent), 
or lowered (prolapse). Also it may be tilted in one of many direc- 

215 



216 



MALPOSITIONS OF THE UTERUS 



tions (version) although its position as a whole with reference to 
the walls, floor, and ceiling of the room has not been changed. 

Alteration of the position of the uterus generally but not neces- 
sarily implies change in its axis, and often in its form. For in- 
stance, retroversion generally means a certain degree of retro- 
position and often retroflexion; prolapse presupposes retroversion 




Fig. 84. — Median Section of the Body of a Woman Who has Borne Children. 
Bladder Empty. (Schultze.) Note Ante version of Uterus. 



in the early stages of the descent of the uterus; inversion is a form 
of prolapse. 

The lesion that is supposed to be the important one from a 
pathological standpoint gives the name to the displacement, al- 
though — as before stated — several lesions are involved. The 
classification here used is a practical rather than a theoretical one. 

In describing the pelvic circulation, Chapter V., page 46, it has 
been stated that the blood-vessels of the uterus and broad liga- 
ments are convoluted, valveless, and capable of great distention, 
depending for their normal tone on absence of constricting; influ- 



GENERAL CONSIDERATIONS 



217 



ences in the way of pressure from tumors or pelvic inflammatory 

masses, or stretching due to malposition of the uterus. 

We know how much a prolapsed uterus is reduced in size after 
it has been replaced in a normal position in the pelvis and main- 
tained there for a few hours even. We know that a normal uterus, 
displaced downward mechanically, becomes congested. It is fair 
to assume that this is due to a straightening of the tortuous valve- 







Fig. 84a.— Longitudinal Median Section of a Pelvis with Overdistended blad- 
der. (Zuckerkandl.) Note Retroversion of Uterus. 



less veins, thus lessening the resistance of their walls to an in- 
creased pressure delivered by the less convoluted arteries. 

It is the view of the author that uterine malpositions have a 
direct mechanical effect on the pelvic circulation, therefore dis- 
placements of the uterus as ;i whole are of more importance than 
changes in the axis (version), or changes in form (flexions, torsions, 

or tumors). 



218 MALPOSITIONS OF THE UTERUS 



I. MALPOSITIONS OF THE UTERUS AS A WHOLE 

1. Ascent. 2. Descent (prolapse). 3. Antero-position. 4. Latero- 
position. 5. Retroposition. 6. Hernia of the uterus. 

1. Ascent 

The uterus is in a position of ascent in the later months of preg- 
nancy; when it is displaced upward by a tumor developing from 
the lower part of the pelvis; when oversupported by a pessary; 
and when it has been attached to the abdominal wall by a ventral 
suspension or fixation operation. The diagnosis is established by 
bimanual palpation. The cervix uteri is far removed from the 
normal situation and in some cases can not be reached by the tip 
of the examiner's finger. The fundus may be palpated through 
the abdominal walls. According to our present knowledge ascent 
is not an important displacement. The only symptom directly 
traceable to ascent is an irritability of the bladder, seen occa- 
sionally, and thought to be due to traction on the vesical neck. 
Prolapse, on the other hand, is extremely important as well as of 
common occurrence. 

2. Descent or Prolapse 

The extent of the descent varies from a slight " falling of the 
womb" to the complete escape of the uterus through the vulvar 
orifice. 

When the uterus remains within the body the displacement is 
spoken of as an incomplete prolapse, or descensus uteri; when it 
is outside the body it is known as complete prolapse, or procidentia. 
This form of displacement is generally of slow development — a 
matter of months and years. 

Acute prolapse, due to violence or sudden straining when the 
uterus is large and heavy, the ligaments weak, and the retentive 
power of the abdominal walls diminished — as after labor — has 
been observed as a rarity. 

Pathology. — The pathology of prolapse includes the morbid 
anatomy of all the pelvic organs involved. The circulation is 
obstructed by traction on the vessels and all the displaced organs 



DESCENT OR PROLAPSE 



219 



become congested; the nerves also are stretched or even sundered. 
The displaced vagina becomes swollen and congested and may be 
ulcerated; there may be hernia of the cul-de-sac of Douglas, and 
the rectum may occasionally send an offshoot into the hernia; 
the bladder is frequently displaced and is subject to catarrh; and 
the endometrium is the seat of endometritis — the uterus being, as 
a rule, much congested. 

Mechanism. — To understand the mechanism of the production 
of prolapse one must consider three factors, (a) The pelvic floor. 
(6) The uterine ligaments and attachments of the uterus to sur- 
rounding structures, (c) The varia- 
tions of pressure exerted by the 
abdominal contents. 

(a) The pelvic floor is a muscular 
and tendinous diaphragm closing the 
outlet of the pelvis. Through this 
diaphragm runs the vagina trans- 
versely and obliquely as a slit. In 
the erect woman the vagina is at an 
angle of about 60° with the horizon, 
terminating above at the neck of the 
womb, which in turn has its long 
axis placed at a right angle to the 
long axis of the vagina. 

The vagina in its course from the 
cervix to the introitus vaginae shows an S-shaped curve when seen 
in a median longitudinal section of the body, the forward bulging 
portion of the S being in its lower portion opposite the under 
edge of the symphysis pubis. (See Fig. 85.) This prominent 
portion of the vagina is made by the presence at this point of 
the chief muscle masses of the levator ani and smaller muscles 
and fasciae making up the pelvic floor. It is the so-called "perineal 
body" of the older gynecologists. By reference to the diagram 
(Fig. 84) it will be seen that this key-stone to the arch of the pelvic 
diaphragm lies about midway between the lower border of the 
symphysis and the coccyx. Injury to the muscles here naturally 
destroys the sigmoid curve of the vagina, opens its outlet, and 
diminishes the support to the structures lying above. The vagina, 
instead of being a flattened ribbon-like canal with walls in apposi- 




Fig. 85. — S-shaped Curve and 
Inclination of Vagina. Note that 
the Walls Are in Apposition. 
(Skene.) 



220 MALPOSITIONS OF THE UTERUS 

tion and running almost transversely from the cervix to the hymen, 
now becomes a straighter open tube, leading almost directly down- 
ward from the cervix to the introitus. 

The pelvic floor, according to Hart and Barbour, may be divided 
up into an anterior and a posterior segment. The anterior seg- 
ment is a relatively movable one, the posterior is relatively fixed. 
The anterior or pubic segment consists of anterior vaginal wall, 
urethra, and bladder, all attached loosely to the symphysis pubis 
by retropubic deposits of fat. The posterior or sacral segment 
is made up of posterior vaginal wall, the muscles and fasciae of 
the perineum, and the rectum, all firmly bound to the sacrum and 
coccyx. During labor the anterior segment is drawn up; the 
posterior segment is driven down. In the formation of prolapse 
the anterior segment, because of the injury of the posterior seg- 
ment, swings downward and backward — the retropubic fat giving 
way with consequent dislocation of bladder and urethra. It is 
plain that a tipping back of the uterus on its axis, so that it may 
get into the same axis as the vagina, is a requisite to the descent 
of that organ, and that this tipping backward is made possible by 
injury of the posterior segment of the pelvic floor and dislocation 
of the anterior segment, so that the cervix — not stayed from be- 
hind and having no firm tissue in front of it — swings forward until 
its long axis coincides with the long axis of the vagina. This 
subject will be made clearer when we consider the different direc- 
tions in which under varying conditions the intra-abdominal 
pressure is applied to the fundus uteri. 

(6) The uterine ligaments and the attachments of the uterus to 
the surrounding structures. 

The ligaments, described in Chapter V, page 44, consist of 
three pairs of ligaments proper — the broad, the round, and the 
utero-sacral ; and the attachments are — the utero- vesical connec- 
tive tissue, the vagina, and the retro-uterine cellular tissue. In 
considering the causation of prolapse we must think of the woman 
being in the erect position, because it is in this attitude that the 
great strain is brought to bear that causes sacro-pubic hernia. 
By reference to the diagram (Fig. 84) on page 216 it will be seen 
that the origins and insertions of all the ligaments lie in nearly 
the same plane. As a matter of fact, the pubic ends of the round 
ligaments are a little lower than their insertions into the horns of 



DESCENT OR PROLAPSE 



221 



the uterus, therefore the round ligaments can not support the 
uterus except in cases of extreme prolapse. On the other hand, 
the attachments of the utero-sacral ligaments to the pelvic wall 
near the second piece of the sacrum are a trifle higher than their 
insertions into the uterus at the level of the internal os. They 
are normally firm and strong and act as true supports. 
The broad ligaments check lateral motion and limit the uterine 



12 th rib 



ThrieTal -ppritiyjeu/n 
oq slanting' shelf 



Crest of ihu/rj 




fkneTai 
periTonevni. 



-5>- 7 n6 



Fig. 86. — Right Side of Abdominal Wall Has Been Removed, Showing Tun- 
nel Shape of Abdominal Cavity, which Is Wide Above and Narrow Below, also the 
Slanting Shelf which Gives Partial Support to the Viscera. (After Corning.) 



movements largely to forward and backward excursions. The 
intra-abdominal pressure is exerted on the posterior aspect of their 
broad surfaces and thereby they assisl either in retaining the 
uterus in anteversion, or, if the axis of the uterus has been changed 
from anteversion to retroversion, the pressure being on their 
posterior aspects, they assist in keeping the womb in that position 
and in aiding prolapse. The thick bases of the broad ligaments 



222 MALPOSITIONS OF THE UTERUS 

intimately joined with the uterus form strong connecting and 
supporting structures between the uterus and pelvic walls. Pro- 
lapse can not occur unless the attachments of the ligaments or the 
ligaments themselves are severed or stretched. The utero-vesical 
connective tissue, when torn asunder by labor or when weakened 
by the atrophy of the triangular mass of subpubic fat, promotes 
retroversion and also prolapse by lessening the resisting power 
of the structures connecting the uterus with the symphysis and 
indirectly diminishing the distance between the cervix and the 
pubes. 

One of the common results of a difficult labor is to loosen the 
attachments of the vagina to the cervix. As seen through a 
speculum with the patient in the Sims or knee-chest position, there 
appears to be little or no intra-vaginal portion to the cervix. In 
these cases the mobility of the uterus is increased and, other things 
being equal, descensus is favored. The attachments of the vagina 
to the cervix serve to steady the uterus and keep it in its proper 
relation to the pelvic floor. 

The retro-uterine cellular tissue has probably very little influ- 
ence on the position of the uterus unless it is the seat of inflamma- 
tory thickening; in which case it fixes the organ. It sometimes 
happens that women who are the subjects of pelvic inflammation 
are relieved of preexisting prolapse only to suffer with it again 
when the exudate has been absorbed. 

(c) The variations of pressure exerted by the abdominal con- 
tents. The reader is referred to Chapter V., page 45, for a partial 
exposition of this subject. Here it is sufficient to say that we have 
to do with (1) downward pressure exerted by (a) increased weight 
of the uterus itself, (b) the weight of the intestines filled with a 
varying amount of solid, fluid, or gaseous matter, and (c) the 
weight of dislocated organs, such as the stomach or kidneys, or 
the weight of a tumor; and (2) additional pressure transmitted to 
the abdominal contents by the walls of the abdomen and by the 
diaphragm in coughing, laughing, straining, jumping, and riding. 

The downward pressure spends itself under normal conditions 
mostly on the lower anterior wall of the abdomen. By consulting 
Fig. 6, page 44, it is apparent that the long axis of the abdominal 
cavity falls at nearly a right angle to the long axis of the pelvic 
cavity, and that the pelvic viscera are protected in a measure from 



DESCENT OR PROLAPSE 



9.93 



pressure directed downward from above by the forward lumbar 
curve of the spine, which, in the normal standing posture of the 
individual, must take some of the weight of the contents of the 
abdomen. A transverse section of the body of the adult virgin 
through the fifth lumbar vertebra shows that at this situation the 
depth of the abdominal cavity from before back is very much less 
than it is in the upper portion of 
the abdomen. For instance, it rep- 
resents only a little over a third 
of the entire thickness of the body 
if measured in the median line from 
the anterior face of the lumbar ver- 
tebra to the skin surfaces of the 
front and back of the body. At 
the level of the twelfth dorsal ver- 
tebra, on the other hand, the 
abdominal cavity takes up over a 
half of the thickness of the trunk 
if measured in the same way and 
occupies a major part of the cubic 
contents of the body at this point. 

When the back is flattened and 
the forward lumbar curve is more 
or less obliterated — as happens in 
the case of the flat-chested, slouchy 
body posture so often ^evn in women 
— more of the weight of the viscera 
will fall on the inlet of the pelvis. 

Under normal condition- there 
IS present a thrust directed forward 
the slanting surface- of the brim of the false pelvis (60° with the 
horizon) that throws the abdominal pressure on to not only the 
lower abdominal wall, but also on to the posterior surface of the 
anteverted uterus and the backs of the wide expanses of the broad 
ligaments. Thus is the uterus maintained normally with its long 
axis at a right angle a1 leasl with the long axis of the vagina. 
As has been stated previously, the axis of the uterus must be 
changed to retroversion before prolapse can occur. Such a change 
in axis is brought about by relaxation of the uterine ligaments, by 




Fig. 87. — Complete Prolapse or 
Procidentia. (After Euguier.) 



inward, and 



downward from 



224 



MALPOSITIONS OF THE UTERUS 



chronic distention of the urinary bladder, chronic fulness of the 
rectum, sudden jar, etc. (see Retroversion, page 234). When 
once the axis has been changed, the intra-abdominal pressure is ex- 
erted against the anterior face of the uterus and the broad liga- 
ments, and increased pressure accentuates the retroversion, and at 
the same time pushes down the uterus, now in the same axis as 
the vagina. Factors which make for greater downward pressure, 
such as a persistent cough or violent straining because of chronic 




Fig. 88. — Prolapse of the Vagina and Cervix, with Elongation of the Supra- 
vaginal Cervix. 



diarrhea, tend to cause descensus uteri. Constant straining is an 
important factor in the causation of prolapse ; therefore prolapse 
is found most frequently among women of the working classes. 
These women are apt to get up and begin work soon after con- 
finement when the uterus is large and heavy and retroverted. 

Inversion of the vagina may take place without actual descent 
of the uterus because of the elasticity of the vagina, and, prolapse 
may be simulated by elongation of the lower uterine segment. 



DESCENT OR PROLAPSE 



225 



True hypertrophic elongation of the cervix, a lengthening of the 
cervix and the lower segment of the uterus, is by no means an 
uncommon condition. In such a case, should the utero-sacral 
ligaments, which ordinarily limit the amount of the descent of the 
uterus, prove to be strong and not susceptible of stretching, the 
fundus uteri may remain nearly at its normal level while the exter- 
nal os presents at the introitus vaginae. A typical case of true hyper- 
tropic elongation of the cervix was reported by Huguier ("Memoire 
sur les Allongements Hypertrophiques du Col de FUterus," 




Fig. 88a. — Hypertrophic Elongation of the Cervix in the Virgin. 



1860, p. 40) as long ago as 1860. A woman twenty-three years of 
age, of poor general health and physique, married two years but 
never pregnant, presented herself for treatment because of pain- 
in the abdomen, dyspareunia, and a tumor in the opening of the 
vagina. Catamenia began at thirteen and she noticed the pro- 
jection at the vulva at fourteen and a half years. It came out 
while she was standing or straining and was reduced on lying 
down. Examination showed the vagina only a little shortened and 
occupied by the enlarged cervix; fundus uteri only a trifle below its 
15 



226 MALPOSITIONS OF THE UTERUS 

normal situation; and the uterine cavity measured five inches (13 
centimeters) in depth. 

Prolapse is largely a disease of women who have borne children. 
It is most common after the menopause when the utero-sacral 
ligaments are prone to be fatty degenerated, the other supports 
of the uterus have lost their tone, and there is increased abdominal 
pressure due to increase in the size of the abdominal contents. It 
occurs infrequently in the nulliparous woman and is then com- 
monly due to retroversion associated with chronic diarrhea or a 
long standing cough; or to increase of abdominal pressure from 
ascites or a tumor. It is probable that stretching of the utero- 
sacral ligaments and a consequent carrying forward of the cervix 
may result from chronic fecal impaction of the rectum. 

Symptoms and Course of Prolapse. — The usual symptoms of pro- 
lapse are: Dragging pains in the pelvic region and difficulty in 
walking; frequency of micturition and vesical tenesmus; inability 
to empty the rectum; leucorrhea, irritation, and pain from vaginitis 
or an ulcerated vagina ; and sterility. It may be necessary for the 
patient to stay in bed in severe cases — often all hard labor has to 
be given up. The course of the disease is chronic as a rule, though 
not infrequently complicated by attacks of acute vaginitis. Occa- 
sionally an attack of peritonitis, by making adhesions and thus 
fixing the uterus, has been known to effect a cure. 

Diagnosis of Prolapse. — In establishing the diagnosis of prolapse 
we consider the clinical history, and, in a less degree, the symptoms. 
The woman is generally at the menopause or has passed it, is the 
mother of one or more children, and belongs to the working classes. 
There is ordinarily a history of a preceding uterine malposition, such 
as retroversion. The appearance of a protrusion at the vulva on 
straining at stool or on other exertion is often a sudden affair and 
may be the first abnormality noticed. The cervix is distinguished 
from rectocele, cystocele, cysts of the vagina, a fibroid polyp, or 
inverted uterus by the presence of the os externum. When the 
prolapse is established, the patient complains of pelvic pains, 
dysuria or frequent micturition, difficult locomotion, and, if the 
rectum is involved in the descent, of inability to evacuate the 
bowel without assistance from the hand. There may be inconti- 
nence of urine from overdistention of the bladder, and the pro- 
lapsed mass may become ulcerated from attrition — in this case 



DESCENT OR PROLAPSE 



227 



soreness and a more or less offensive discharge will claim the pa- 
tient's attention. 

As has been stated already, prolapse is usually of gradual develop- 
ment. In some cases, however, it is acute, in which case reposition 
will more often result in a permanent cure than in the chronic cases. 

The patient should be examined first in the dorsal position. 



v 












Fig. 89.— Partial Prolapse of the l't ems and Vagina. The Light Spot Shows 
the Situation of the Tip of a Sound in (he Bladder, Marking (he Lowest Poinl 
of the Bladder. (Kelly.) 

If the 1 prolapse is only partial an examination in the standing 
position should be made also, the patient bearing down so as bo 
drive out the hernia to its bill extent. There is seldom much 
difficulty in making the diagnosis. The important points are to 
determine the extent of the downward dislocation of the uterus; 
the exact size, position, :m<l shape of this organ; the situation 



228 MALPOSITIONS OF THE UTERUS 

of bladder, urethra, and rectum — also the ovaries and tubes — 
and the amount of prolapse and the condition of the vagina. In 
most cases of prolapse the vagina becomes thickened to a marked 
degree and takes on the characteristic of skin, and ulceration may 
develop in its structures. These items are to be noted carefully 
because upon them depends the form of treatment employed and 
its success. 

A conjoined recto-abclominal examination determines the situ- 
ation of the fundus uteri. A sound passed into the uterine cavity 
shows its depth, size, and shape, and whether or not any polypi are 
situated there. The cleansed sound passed into the urethra shows 
the direction of the canal and whether any portion of it is dislo- 
cated downward and, if so, how much. It also shows the limits 
of the bladder in the prolapsed mass by noting the situation of the 
point of the sound on the vagina both by sight and touch. (See 
high light in Fig. 89, marking tip of sound in bladder.) A finger 
hooked through the anus shows whether the rectum has been dis- 
located downward. It may be possible to palpate the whole of 
the uterus outside the vulva through the walls of the inverted 
vagina, but in most cases, for the purposes of diagnosis, it is best to 
reduce the prolapse. This is done by covering it with muco- 
lubricans and making gentle upward pressure, at the same time 
squeezing the mass a little, and in some cases it may be necessary 
to place the patient in the knee-chest position before resorting to 
this measure. When the mass has been reduced a bimanual ex- 
amination is made with the patient in the dorsal position and the 
size and shape of the uterus mapped out anew. It is now possible 
to determine true hypertrophic elongation of the lower segment 
of the uterus, fibroid nodules, the location of the ovaries, etc. If 
the vaginal walls are much thickened the tactile sense of the ex- 
aminer's finger will be blunted. In this event a recto-abdominal 
examination will prove to be more satisfactory. 

Differential Diagnosis of Prolapse. — An inverted uterus may be 
mistaken for a prolapse. The absence of a distinct ring having a 
sharp edge completely surrounding the prolapsed mass-, and the 
fact that at no point can a sound be passed into the tumor, serve 
to distinguish the two. If the abdominal walls happen to .be ex- 
tremely thin a cup-shaped depression in the abdominal aspect of 
an inverted uterus may be made out by bimanual touch. 



LATEROPOSITION 229 

True hypertrophic elongation of the lower uterine segment (Fig. 88a) 
has been spoken of as a part of prolapse. It is diagnosed by dis- 
tinguishing unusual length of the lower part of the uterus by bi- 
manual touch, by finding a fundus placed relatively high in the 
pelvis, and increased length of the cervical canal, as disclosed by 
measuring the sound passed only to the internal os, — the point 
where the tip meets an obstruction. When the patient is placed 
in the knee-chest position the cervix is not obliterated, as under 
normal conditions. True hypertrophic elongation occurs only in 
sterile women; false hypertrophic elongation, occurring in the parous, 
is described in the chapter on laceration of the cervix, page 209. 

A pedunculated fibroid or polypus is sometimes mistaken for a 
prolapse. In this case a sound can be swept about in the uterine 
cavity at any point in the circumference of the collar of the cervix 
except at the side where the polypus is attached to the uterine wall. 
There is no cavity in the polypus, and recto-abdominal touch re- 
veals the presence of the fundus uteri in its normal position. 

3. Anteroposttion - 

Anteroposition of the uterus, or a uterus placed as a whole too 
near the symphysis pubis, is due to retro-uterine tumors, such as a 
pelvic hematocele, dermoid ovarian tumor, or tumor of the rectum, 
or even an overloaded rectum. As far as we know, this position 
of the uterus is of no significance from a pathological or clinical 
point of view. The diagnosis is established by the bimanual 
touch; noting that the uterus is not in its normal sit nation but 
close against the pubic arch. 

4. LATEROPOSITION 

The uterus may be displaced to the right side or to the lefl side 
by a tumor or an inflammatory mass, the uterus being pushed fco 
the opposite side of the pelvis to thai occupied by the tumor mass. 
Cicatricial contraction following an effusion in one broad ligament 
may draw the uterus to that side of the pelvis. Such a malposi- 
tion is to be noted for the purpose of removing its cause and 
has significance only because of the pathological condition pro- 
ducing it. 



230 



MALPOSITIONS OF THE UTERUS 



5. Retroposition 

This is an important malposition which is almost always attended 
by dysmenorrhea. It is often spoken of as retroversion and also 
as anteflexion. Dissimilar as these abnormalities appear to be, 
there are comparatively few cases of retroversion or anteflexion 
that do not have a certain amount of retroposition. The placing 
of the uterus backward near the sacrum seems to be the important 




Fig. 90. — Anteflexion in the Little Girl. (Schultze.) 

factor in the causation of symptoms. The immobility of the uterus 
in this position is undoubtedly the chief factor in the causation of a 
large class of cases of anteflexion, and the fixity of the organ close to 
the hollow of the sacrum, rather than its anteflexion, is the deter- 
mining element in the production of the symptoms from which 
patients with these abnormalities suffer. The retropositions asso- 
ciated with retroversion will be taken up under the head of retro- 
version. Here we will discuss the very common uterine disease, 
retroposition with anteflexion. 



RETROPOSITION 



231 



Retroposition with Anteflexion. — By reference to the figure 
taken from B. S. Shultze's ''Displacements of the Uterus," Fig. 90, 
it will be noted that in the little girl — the bladder and rectum being 
empty — the uterus is normally in a state of anteflexion; that the 
vagina is relatively long; the long axis of the cervix — also long with 
reference to the length of the corpus — is nearly in the axis of the 
vagina; the intravaginal anterior lip of the cervix is short; and 




o 



a 



C7Q 



Fig. 91. — Pathological Anteflexion Arising from Contraction of the Utero- 
sacral Ligaments, (a) Direction of the Pull of the Ligaments. (6) Direction 
of the Intra-abdominal Pressure. (Schultze.) 

the region of the internal os is high up, because the entire uterus is 
in the false pelvis, and is near the sacrum. The uterus is not fixed, 
however, in this position. This condition, then, is normal to the 
growing girl before puberty. 

Fig. 91 shows retroposition with anteflexion, the old so- 
called "pathological anteflexion." The similarity of the two 
conditions is striking, and it seems fair to draw the inference that 
retroposition with anteflexion is a persistence of the puerile state, 



232 MALPOSITIONS OF THE UTERUS 

with the addition, in the case of retroposition with anteflexion, of 
adhesions limiting the mobility of the uterus. 

Anteflexion may be acquired, however, as in the case of a uterus 
with softened tissues having a fibroid in the anterior wall of the 
fundus. Excessive straining at stool tends to bend the cervix 
forward and at the same time to fold the fundus and bod}' of the 
uterus forward and downward, provided the forward excursion 
of the region of the internal os is limited. Thus a flexed uterus 
becomes more flexed. The uterine canal is obstructed mechan- 
ically at the internal os by excessive flexure, therefore we should 
expect these patients to suffer with blood stasis and endometritis, 
the results of a damming up and decomposition of the uterine dis- 
charges, and this is usually the case. 

Vesical symptoms are due to the backward traction of the cervix 
on the vesical neck and to the interference offered by the forward 
flexed fundus uteri to the filling of the bladder. Of the two the 
former is the more important cause. 

I have previously called attention to the frequency of retro- 
position with anteflexion (" Division of the Utero-Sacral Liga- 
ments and Suspensio Uteri for Immobile Retroposition with Ante- 
flexion," Amer. Gyn. and Obstet. Jour., Jan., 1898, and " Further 
Experience with the Operative Treatment of Anteflexion/' Amer. 
Gyn. and Obstet. Jour., Jan., 1900). The condition has not been 
recognized generally by the profession, having been classed broadly 
as retroversion. 

Diagnosis of Retroposition with Anteflexion. — The diagnosis is 
made by finding the uterus as a whole in the extreme back part of 
the pelvis. This is done by practising the bimanual vagino- 
abdominal or recto-abdominal touch. The cervix is in the axis 
of the vagina, the anterior lip is flattened and short, the crown of 
the cervix being in extreme cases practically continuous with the 
front wall of the vagina. The cervix, in the axis of the vagina, is 
not so long, as a rule, as in the case of the puerile cervix, but it is 
long as compared with the fundus, representing two-thirds of the 
entire length of the uterus. Its tissues are generally indurated 
and more or less tender; there is a cervical discharge from a pin- 
hole os. The fundus is flexed forward and may be grasped be- 
tween the forefinger in the vagina and the fingers of the hand on 
the abdomen. It may be enlarged or it may not, and tenderness 



HERNIA OF THE UTERUS 233 

on pressure and induration are not necessarily present. Shortened 
utero-sacral ligaments or extraligamentous adhesions — these latter 
rarely present — limit the forward excursion of the uterus as de- 
termined by making forward traction with the examining hands. 
Rigidity of the tissues at the angle of flexion is determined by 
manipulating the uterus. Downward pressure on the fundus by 
the hand on the abdomen moves the cervix backward, and up- 
ward pressure on the fundus by the finger in the vagina moves 
the cervix forward. It is impossible to change the relation of 
cervix and fundus to each other by separating two fingers placed 
between them in the vagina. 

As a rule it is not necessary to pass the sound in order to verify 
the diagnosis. In fat women, however, with thick and rigid 
abdominal walls, this procedure may be necessary. Select a flex- 
ible sound of small caliber. This is better and safer than a probe, 
the tip of which will catch in pockets of the lining mucous mem- 
brane. Bend the sound so that it corresponds to the bent uterine 
canal as determined by palpation; fix the cervix with a tenaculum 
and make gentle traction, thus straightening the uterine canal as 
much as possible. Pass the sound tentatively, withdraw and 
rebend, until the tip will slip through the internal os. Note the 
point of sensitiveness in the uterine canal, if any, the distance of 
the internal os from the external os, and the total depth of the 
uterine cavity. Note thus the relation that the length of the 
cervical canal bears to the length of the uterine cavity proper; 
also consider the tightness of the internal os, the capacity of the 
uterine cavity, and the amount and character of the discharge. 
If blood follows the gentle passing of the sound and tenderness is 
present, one may diagnose endometritis. 

6. Hernia of the Uteris 

Hernia of the uterus through the inguinal or the crural canal is 
a rare anomaly. The diagnosis is established by determining the 
absence of the uterus from its normal situation and Its presence in 
the hernial sac. The latter is a most difficull matter and most of 
these eases have been operated on for strangulated hernia, when 
the diagnosis was made. Congestion or tumefaction of the hernial 
tumor containing a uterus should be looked for at the time oi 



234 MALPOSITIONS OF THE UTERUS 

menstruation. If the displaced uterus becomes pregnant — as it 
has in a few cases reported in the literature — the tumor becomes 
progressively larger as pregnancy advances and the symptoms and 
signs of pregnancy are present. 



II. ABNORMALITIES OF THE AXIS AND FORM OF THE UTERUS 

1. Retroversion; Retroversio-flexion. 2. Anteversion. 3. Ante- 
flexion. 4. Inversion. 5. Torsion. 

1. Retroversion 

Retroversion is that abnormal position of the uterus in which 
the long axis of the organ is tilted backward to or beyond the long 
axis of the vagina. Retroflexion signifies the bending backward 
of the fundus and body alone — a flexing of the uterus — and there- 
fore a change only in form. Retroversion and retroflexion are 
commonly associated. They present similar pathological condi- 
tions both as regards the tissues of the uterus itself and the sur- 
rounding organs; their symptoms are the same; therefore, they 
will be considered together. 

Retroversio-flexion. — This is one of the commonest uterine mal- 
positions. As has been pointed out in describing the mechanics 
of prolapse, in order that the uterus may be retroverted it is neces- 
sary for the cervix to leave its normal position — it must move 
forward — for with the cervix normally situated there is not suffi- 
cient room for the fundus and body between the cervix and the 
unyielding sacrum. Retroversion, then, presupposes a stretching 
of the utero-sacral ligaments. Any abnormality tending to draw 
the cervix forward will figure as a cause of retroversion, such as a 
bad vesico-vaginal fistula, and chronic cystitis with contracted 
bladder, thus shortening the anterior wall of the vagina. This, 
fortunately, is an unusual condition. Congenital retroversion is 
very rare, but after the menopause the small senile uterus is found 
frequently in this position. Relaxation of the uterine ligaments 
is the chief cause of retroversion. Added to this are : habitual 
distention of the bladder; chronic distention of the rectum; in- 
creased weight of the uterus; retro-uterine peritonitis; adhesions 
pulling back the fundus; chronic cystitis, with contracted bladder; 



RETROVERSION 



23.5 



Hinall myoma in the posterior wall of the fundus, and sudden 
straining or a violent fall. When once the axis of the uterus lias 
been turned backward every act of defecation or straining tends 
to push the fundus further toward the sacrum because the thrust 
of the intra-abdominal pressure 4 acts on the anterior rather than 
on the posterior face of the fundus. It is probable that backward 
tilting of the pelvis on the spine, with flattening of the forward 
lumbar curve of the spine, due to faulty attitude while standing, 
has something to do with the causation of this uterine malposition, 




Fig. 92. — Retroversion of the Uterus. 



for if the plane of the pelvic inlet becomes more nearly horizontal 
and at the same time the inlet is not protected from above by the 
forward projection of the lumbar spine, the intra-abdominal pics- 
sure is transmitted more directly to the contents of the pelvis and 
from a more forward direction. This pressure 1 from the front is 
accentuated by the contractions of the abdominal muscles in strain- 
ing, thus throwing backward large masses of intestine from a pro- 
tuberant abdomen, which is often present in these cases. 

The puerperium, with its lax, non-involuted uterine ligaments, 
increased weight of the uterus coupled with the normal retrover- 
sion from the patient's recumbent position, is a peculiarly favor- 
able time for the malposition to begin. It is not easy to explain 
the causation of retroversion seen so commonly in young unmar- 



236 MALPOSITIONS OF THE UTERUS 

ried women. Possibly habitual constipation and overdistention 
of the bladder and faulty posture may have something to do 
with it. The symptoms of retroversio-flexion are not distinctive 
and there may be no symptoms. If present, they are: a sense of 
weight in the pelvis or bearing-down feeling, irregularities of men- 
struation, uterine catarrh, constipation, frequency of micturition, 
and abortion and sterility. In the case of retroflexion, if preg- 
nancy occurs in the retroflexed fundus there is less likelihood of 
spontaneous reposition than in retroversion, and therefore abortion 
is more likely to occur. The bladder and rectal symptoms are 
apt to be more pronounced in retroflexion than in retroversion 
because in the former there is more dragging on the neck of the 
bladder and a sensitive fundus impinges more directly upon the 
lower rectum. The degree of retroversion is a variable quantity. 
Formerly it was customary to define the amount of tipping of the 
uterine axis with great exactness and the retroversion was said to 
be in the first, second, or third degree, according as it was tipped 
backward so that its long axis pointed, respectively, at the promon- 
tory of the sacrum, in the axis of the vagina, or it exceeded the 
last amount of tilting. Now we consider the old first degree to 
be within normal limits. It is well, however, to preserve these dis- 
tinctions for purposes of description. 

Diagnosis of Retroversio-flexion. — The bimanual touch shows the 
fundus to be absent from its normal situation and the cervix in the 
axis of the vagina. If the abdominal walls are thin and relaxed 
it is possible often to palpate the fundus bimanually, even though 
it is retroflexed. In less favorable cases the hand on the abdomen 
determines the absence of the fundus in its normal position. The 
finger in the vagina notes a sense of resistance in the cul-de-sac, 
or in the case of retroflexion, a rounded body in that situation. 
Rectal touch is of great assistance in the diagnosis of both retro- 
version and retroflexion, for by the rectum the examiner's finger 
can reach a higher point in the pelvis than by the vagina. One of 
the most important facts to determine is the mobility of the uterus ; 
therefore attempt to dislodge it. To do this, make an upward pres- 
sure on the fundus by the left forefinger — protected by a cot — in 
the rectum while the cervix is pushed backward by the right fore- 
finger in the vagina, the patient being in Sims position. If this 
is unsuccessful, hook a tenaculum into the cervix and make down- 



RETROVERSION 237 

ward traction while the rectal ringer pushes the fundus up. If 
the fundus has been displaced from the hollow of the sacrum by 
these manipulations the tenaculum is removed from the cervix, the 
left forefinger— the cot having been removed — is transferred to 
the vagina, the right hand is passed between the patient's thighs 
to the abdomen and the uterus rocked into place by the bimanual 
touch. The knee-chest position and traction on the cervix with 
a tenaculum will often accomplish the reposition of an obstinate 
retroversion or an incarcerated pregnant fundus. Sometimes the 
displaced fundus is held between the utero-sacral ligaments. When 
the uterus is raised in the pelvis these ligaments are relaxed and 
the fundus may be pushed up through them. In some cases, es- 
pecially in virgins with tense, well-developed abdominal walls, noth- 
ing short of an anesthetic will permit reposition of a retroflexed 
uterus even though free from adhesions. During the manipu- 
lation the physician gains a knowledge, through his sense of touch, 
of the other pelvic organs. He detects salpingitis or thickenings 
denoting adhesions. He notes points of tenderness, and these warn 
him against vigorous attempts at reposition. When the Peaslee 
rigid uterine sound was first invented it was customary for the 
practitioner of that day to pass it into the uterine cavity and 
forcibly pry the uterus into place, and the trauma, together witli 
the lack of asepsis which prevailed at that time, produced most 
disastrous results in the form of acute pelvic inflammation, salpin- 
gitis, or even pelvic abscess. 

Suppose the fundus has been freed from its abnormal position, 
the next procedure is to hold the cervix backward while you reach 
for the fundus with the fingers of the right hand on the abdomen, 
working them behind it by gradual and repeated pressure as the 
patient takes deep inspirations. Backward pressure on the cervix 
and forward rocking on the fundus restore the uterus to its normal 
position. The bimanual touch practiced in the Sims position i< 
most useful for this procedure. Always be sure that the bladder 
is empty before beginning the manipulations. II* the uterus comes 
up do the ovaries also assume a normal position? Note their size 
as well as their mobility. In exceptional cases the aseptic sound 
may be passed to confirm a diagnosis, especially in cases of retro- 
flexion. Here it is generally necessary to pass a sound to differ- 
entiate from a fibroid in the posterior uterine wall, h is nec( 



238 MALPOSITIONS OF THE UTERUS 

to exclude an inflammatory mass or abscess posterior to the uterus, 
and this is done by noting the shape and situation of the inflamma- 
tory mass. Recto-abdominal touch shows it to be situated in the 
recto-vaginal septum, and it is generally a little to one side or to 
the other, and not, like the retroflexed fundus, directly in the 
median line. A scybalous mass in the rectum is detected by 
rectal touch. In doubtful cases cleanse the rectum by a suds 
enema. 

In diagnosing retroversio-flexion it is often not advisable to make 
a complete diagnosis at one sitting. Sometimes the best plan is 
to pack the vagina with cotton tampons, cleanse the bowel by a 
cathartic, and see the patient again after a lapse of two days, 
when it will be found that a retro verted uterus has been replaced. 
In other cases the presence of pelvic inflammation or salpingitis in 
a chronic stage makes replacement inadvisable. In such cases 
treatment with glycerin tampons, vaginal suppositories, and 
douches is to be employed until the subsidence of the inflamma- 
tion. After a second or third examination the physician will have 
a better idea as to the pathological condition of the pelvic organs 
and will be in a position to advise, if necessary, etherization for a 
complete diagnosis. Progressing too fast or too vigorously has 
often done great damage by lighting up dormant inflammation, 
rupturing adhesions, and causing hemorrhage, or squeezing pus 
from inflamed tubes. 

2. Anteversion 

This is of little importance clinically and is to be classed with 
lateroposition or lateroversion. Sometimes frequency of micturi- 
tion is found in cases of anteversion ; in this case it is due, appar- 
ently, to traction made on the neck of the bladder by the exagger- 
ated posterior position of the cervix, for the symptom is clone 
away with by elevating the fundus with a Hodge or Gehrung 
pessary. The diagnosis is established by the bimanual touch, 
the fundus being found well clown behind the symphysis pubis 
and the cervix high in the pelvis. The axis of the uterus coin- 
cides very nearly with the axis of the vagina in extreme degrees 
of anteversion. 




Fig. 93.— Acute Puerperal Inversion of the Uterus. (Dudley.) 



239 



240 MALPOSITIONS OF THE UTERUS 

3. Anteflexion 

Anteflexion has been described at length under Retroposition 
with Anteflexion. It is to be understood that this malformation 
of the uterus does occur without the posterior malposition. What 
has been said of the combined disorder applies equally to the 
flexion alone. 

4. Inversion 

Inversion of the uterus is a partial or complete turning of the 
organ inside out. It is of three sorts: (1) acute puerperal inver- 
sion, (2) chronic puerperal inversion, and (3) inversion caused by 
uterine tumors. The first sort concerns the obstetrician. The 
second is the more usual of the remaining two forms that are seen 
by the gynecologist. 

Puerperal inversion is due to relaxation of the uterine muscles 
at the time of the delivery of the placenta. Coughing or sneezing 
may invert a relaxed uterus; too much traction on the cord and 
an adherent placenta are the direct causes in some cases. The 
uninverted part of the uterine wall may seize the inverted part 
so that the uterus looks like the bottom of a wine bottle, and the 
contraction of the unrelaxed portion may continue to push the 
fundus downward until the uterus is completely inverted. The 
process may start in the lower uterine segment, which is inverted 
first, and is followed by the fundus. The tubes follow necessarily 
into the cup of the inverted fundus and sometimes also loops of 
intestines, but these structures are seldom adherent. The everted 
mucosa of the uterine cavity is dark red and bleeds easily, and in 
cases of long standing inversion it shows regions of ecchymosis 
and ulceration. Cases have been reported where there were ad- 
hesions between the partially inverted fundus and the cervix. 
If inversion is due to downward traction on the uterine wall by a 
submucous fibroid there is apt to be present a foul uterine dis- 
charge, for the fibroid is generally in a state of necrosis. The 
usual sjmiptoms of chronic inversion are: pelvic pain, hemorrhage, 
leucorrhea, frequency of micturition and dysuria, and difficulty in 
walking and standing. 

Diagnosis of Inversion. — In favorable cases where the abdominal 
walls are relaxed and the patient is not fat, the bimanual touch will 




Fig. 94. — Partial Inver- 
sion of the Left Horn of 
the Uterus. 






Fig. 95 — Pedunculated 
Submucous Fibroid Sim- 
ulating Partial Inversion. 



Fig. 100— Complete In- 
version Complicated by 
a Subperitoneal Fibroid 
which Resembles the 
Uterus. 



Fig. 96.— Partial Inver- 
sion Complicated by and 
Caused by a Submucous 
Fibroid. 






Fig. 97. — Partial Inver- 



Fig. 101. — Submucous 
Fibroid Filling the Vagina 
with Normally Situated 
Uterus Above Simula! ing 

Condition in last Figure. 




Complete 



version. 



Fig. 99.- Pedunculated 
Submucous Fibroid Pro 
jectingfrom the External 
()s. Resembling an In- 
verted Uterus. 



Eight Diagrams Showing [nversion of the Uterus \\j> Conditions 
15 Simulating it. (Dudley) Figs. 94-101. 



242 MALPOSITIONS OF THE UTERUS 

show the absence of the uterus in its customary situation. Rectal 
touch is of great use, also the recto-abdominal touch, and the 
rectal touch with a sound in the bladder. In extremely favorable 
cases the depression of the inverted cup may be made out by the 
abdominal hand. By vagina the partial or completely inverted 
uterus is felt and seen, and occasionally the orifices of the Fallopian 
tubes can be demonstrated in the inverted fundus. The ring of 
the cervix can be felt by the finger swept about the inverted fundus. 
The difficult point in diagnosis is to differentiate complete inver- 
sion from submucous myoma. 

By reference to the figures on page 241, it will be seen that a 
myoma may spring from the fundus, body, or cervix. It may be 
sessile, or have a short pedicle or a long one. Fig. 100 shows 
an unusual condition: a pedunculated subperitoneal fibroid at- 
tached to the cervical region — the uterus being in a state of com- 
plete inversion — and the fibroid tumor presents to the examiner's 
touch the size and shape of a uterus in a normal situation. In 
such a case it would be extremely difficult to tell the uterus from 
the tumor. Detection of the orifices of the Fallopian tubes and 
also the ring of the cervix would be the distinguishing features. 
Complete prolapse can be differentiated from an inversion by 
finding in the prolapse the external os uteri; the extruded mass 
is wider above and narrower below; and the vagina is everted to a 
greater or less degree, as shown by the fact that the point of a 
sound introduced into the bladder can be felt in the hernia. In 
the case of inversion, on the other hand, there is no external os, 
the orifices of the tubes may be seen, and a sound in the bladder 
goes upward, except very rarely when the vagina also is inverted. 

Differential Diagnosis of Inversion. — The following is a tabulated 
statement of the differential diagnosis between complete inversion 
and pedunculated fibroid in the vagina, and incomplete inversion 
and intra-uterine submucous fibroid. 



Complete Inversion. Pedunculated Fibroid in Vagina. 

1. Sweeping finger and sound about 1. Tumor is attached at one point by- 
tumor shows it to have no point of at- a broader or narrower attachment, 
tachment. Verify location and size of attachment 

by the sound. 

2. Sound will enter ring of cervix but 2. Sound goes to fundus a distance 
a short distance. f 2\ inches (six centimeters), at least. 



TORSION 243 



Complete Inversion. Pedunculated Fibroid in Vagi 

(continued) (continued) 



/tu. 



3. Uterus absent in abdomen to bi- 3. Uterus present in abdomen, 
manual examination. 

4. Hernia mass is symmetrical, lar- 4 - Mass may be asymmetrical. 
ger below and narrower above. 

5. Orifices of the Fallopian tubes are 5. Xo orifices of the Fallopian tubes. 
often demonstrable. 

Incomplete Inversion. Intra-Uterine Submucous Fibroid. 

1. Uterine cavity is shallow as meas- 1. Cavity deep. 
ured by sound. 

2. Cup-shaped depression in uterus 2. Xo cup-shaped depression, 
felt bimanually. 

3. Symptoms date from parturition. 3. Symptoms do not date from par- 

turition. 



5. TORSIOX OF THE UTERUS 

Torsion, or twisting of the uterus on its own long axis, may be 
complete or it may be partial. In the former the entire uterus is 
twisted to one side or the other, generally not more than half a 
turn, as in the cases of anteflexion or retroflexion where one 
utero-sacral ligament is shortened. In the case of tumors growing 
from one side of the pelvis, however, the uterus may be twisted 
several times on its own axis. Torsion of the uterus occurring with 
a fibroid of subserous evolution, or an ovarian tumor having a 
short pedicle, is generally partial. The cervix uteri, being steadied 
by the insertions of the broad ligaments, is not so apt to partici- 
pate in the twist and the uterus is twisted on itself, the fundus 
and body alone taking part in the twist. 

Torsion is especially apt to be found in the ease of double uterus 
or uterus bicornis. 

The diagnosis is made by determining by the bimanual touch 
the position of the ovaries and also the situation and direction of 
the transverse axis of the fundus with reference to the cervix. In 
the event of complete torsion of the uterus the transverse axis of 
the external os may be seen through the vaginal speculum to be 
turned away from the normal. 



CHAPTER XV 

THE DIAGNOSIS OF FIBROID TUMORS OF THE UTERUS 

Definition, p. 244. Pathology, p. 244. Classification, p. 245. Situation, 
p. 248. Frequency, p. 248. Etiology, p. 250. Course and Develop- 
ment, p. 251. Degenerations, p. 252. Complications, p. 255. Effect on 
neighboring organs, p. 257. Effect on distant organs, and on the system, 
p. 258. Relation of fibroid tumors to heart disease, p. 259. Dangerous 
to life, p. 260. Symptoms, p. 260. Symptoms of adenomyoma, p. 262. 
Diagnosis and differential diagnosis, p. 262. Subserous fibroids, p. 262. 
Intraligamentous fibroids, p. 263. Interstitial fibroids, p. 263. Submucous 
fibroids, p. 264. 

DEFINITION 

Fibroid tumor, also called myoma, fibromyoma or fibroma of the 
uterus, is a nodular growth developing from some portion of the 
uterus, usually, but not always, above the cervix, varying in size 
from a minute speck to a mass or masses filling the pelvic and 
abdominal cavities. 

PATHOLOGY 

The largest fibroid which I have found recorded was one re- 
moved at autopsy from a single woman fifty-three years of age 
by S. H. Hunt of Long Branch, N. J. (Amer. Jour. Obstet., 
1888, XXL, p. 62.) It weighed one hundred and forty pounds 
and the cadaver after the removal of the tumor weighed ninety- 
five pounds. 

The tumors are generally round in shape, with smooth surface, 
but may be pear-shaped, kidney-shaped, mulberry-shaped; may 
be molds of the pelvic cavity, or, very rarely, may resemble a 
fetus. They are single or multiple, as many as one hundred and 
fifty tumors having been found in the uterus by Bland-Sutton. 
(Brit. Med. Jour., April 6, 1901.) They are of a hard consistence, 
though a predominance of muscular tissue in their structure, or 
degenerative changes, may render them softer. They are classed 

244 



CLASSIFICATION 245 

as benign tumors because they do not "eat up" the surrounding 

tissues by extending into their substance, and they do not cause 
destruction by metastases. They are composed of the same tissues 
as the uterus, namely, unstriped muscle fibers and connective 
tissue. On section a fibroid tumor is of a glistening white, or 
whitish-yellow color and is seen to be made up of a disorderly 
intertwining of muscular and connective-tissue fibers. In the Larger 
masses, however, these are grouped in more or less well-defined 
whorls (see Fig. 106) which somewhat resemble knots in a piece 
of wood. Between the groups of fibers run arteries, veins, and 
lymph channels derived from the normal vessels of the uterus, 
ramifying at first beneath the capsule of the tumor and then 
plunging directly into its interior. As a rule these tumors are 
poorly nourished because they derive their blood from the sur- 
rounding constricted uterine tissue. Occasionally they are sup- 
plied by large vessels through adhesions to surrounding organs. 



CLASSIFICATION 

Fibroid tumors may be classified according to their situation with 
reference to the uterus. They are — 

1. Subserous, 

(a) Intraligamentous. 

(b) Tumors of the cervix. 

2. Interstitial. 

3. Submucous. 

They are described further by defining their number and size, 
and by noting any special kind, as adenomyoma. For instance, 
in Fig. 102 we see a specimen of a multiple fibroid uterus: an 
interstitial fibroid of the anterior uterine wall, a subserous fibroid 
springing from the fundus uteri, and an interstitial tumor of the 
posterior wall. All fibroids originate in the uterine muscle, there- 
fore all are interstitial in the beginning. It' the tumor develops in 
the outer wall of the uterus and grows from the uterus under the 
peritoneum, it is called an adenomyoma. 

Adenomyoma is a special variety of myoma characterized by the 
presence of glands similar to those found in the uterine mucosa. 
Thomas S. Cullen ("Adenomyoma of the Uterus" L908) found 



246 



DIAGNOSIS OF FIBROID TUMORS OF THE UTERUS 



73 cases of adenomyoma among 1283 cases of myoma examined 
microscopically in the Johns Hopkins Hospital Surgical-Patho- 
logical Laboratory during thirteen years, or 5.7 per cent of all 
fibroids. These tumors are diffuse and may or may not be definitely 
encapsulated. 

1. Subserous Fibroid Tumor. — Such tumors have the greater part 
of their periphery outside the uterine wall and have no considerable 
covering of uterine tissue. (See Fig. 102, upper tumor.) The 




Fig. 102.— Multiple Fibroids, One Subserous and Two Interstitial. (Winter.) 



greater the size of the subserous tumor the more it is separated 
from the uterus, as a rule. It may be relatively small or large. 
If, instead of developing under the serosa, the tumor separates the 
folds of the broad ligament and distorts the viscera to a greater or 
less degree, it is called an 

(a) Intraligamentous Fibroid Tumor. (See Fig. 105.)— These 
tumors have the greater part of their circumference outside the 
uterus and are not covered by uterine tissue. Noble (" Gynecology 
and Abdominal Surgery/' II. A. Kelly and 0. P. Noble, 1907, p. 669) 



CLASSIFICATION 247 

found this form of tumor in 3.5 per cent of the 2,274 cases of fibroid 
tumor he studied. The same characteristics belong to 

(b) Tumors which originate in the lower posterior segment of the 
uterus and grow into the cervix and then into the posterior pelvis, 
or those rare tumors which originate in the cervix itself and de- 
velop away from the uterus. (See Fig. 108.) The cervix, to 
be sure, has no covering of peritoneum. As the tumor incn 
in size and rises in the pelvis it pushes the peritoneum before it. 
Therefore, this class of tumors may be included among the sub- 




Fig. 103. — Large Multinodular Subperitoneal Fibroid with Thin Abdominal 

Walls. Seen in Profile. (Kelly.) 

serous. In subserous fibroids the uterine cavity is altered little if 
at all in length or shape. 

2. Interstitial (intramural, intraparietal) fibroid tumors are those 
which arc situated in the wall of the uterus and are surrounded 
by a covering of uterine musculature. (See Figs. L02 and 101. > 
They may or they may not alter the contour of the uterus. The 
uterine cavity is almost always lengthened, and it may be broad- 
ened and made asymmetrical in shape by this form of tumor. 

3. Submucous Fibroid Tumors. These are the tumors which 
velop into the uterine cavity and are covered with mucous mem- 
brane and with little, if any, of the uterine musculature. 

Figs. 104 and 100.) Of all the three varieties these cause the 
greatest changes in the form of the uterine cavity. Tin-' are 



248 DIAGNOSIS OF FIBROID TUMORS OF THE UTERUS 



the bleeding fibroids. The pressure exerted by the tumor on 
the nervous mechanism of the uterus sets up reflex uterine con- 
tractions producing a gradual delivery of the tumor. At first 

the tumor becomes pedunculated; then 
the pedicle is elongated until the inter- 
nal os has been dilated. Finally, in 
favorable cases, the tumor is delivered. 
More often necrosis of the tumor sets 
in before the delivery is accomplished, 
and we have a Sloughing Fibroid. 

A pedunculated submucous fibroid, 
if of small size, is called a fibroid 
polyp (see Fig. 107), and is to be dis- 
tinguished from a mucous polyp, one of 
the manifestations of glandular endo- 
metritis. In all forms of fibroids, more 
especially in the submucous and the in- 
terstitial, the mucous membrane of the 
corpus uteri may show evidences of 
glandular and interstitial endometritis. 
Kelly and Cullen ("Myomata of the 
Uterus") state that the mucous membrane of the uterine cavity 
is generally normal, but that cervical endometritis is relatively 
frequent when a sloughing submucous myoma exists, otherwise 
it is rare even if there be present evidences of an old inflamma- 
tory process in the ovaries and tubes. Therefore they point out 
that the surgeon may open the uterine cavity with impunity in 
the absence of vaginal discharge and signs of tubal disease. 




Fig. 104. — Interstitial and 
Submucous Fibroids. 



SITUATION 

Fibroid tumors always originate in the substance of the uterine 
wall. They almost always develop in the body rather than in 
the neck of the uterus, and they are more commonly found in the 
posterior than in the anterior or lateral walls. 



FREQUENCY 

Fibroid tumors are the most prevalent of all neoplasms affecting 
the uterus. As regards their frequency among women, most 



FREQUENCY 



249 



authors quote Bayle (S. H. Bayle, "Diet." on 60 vol., Paris, 1813, t. 
VII., p. 73) who stated as long ago as 1813 that 20 per cent of all 
women over thirty-five years of age have fibroids; but as other 
authors have arrived at different results (Klob, for instance, assert- 
ing that 40 per cent of the uteri of women who die after the fiftieth 
year contain fibroid tumors), and as Bayle' s opinion has not been 
confirmed, we may state that the exact frequency of the tumors is 
yet to be determined. They are met with mostly during the period 
of sexual maturity, between the ages of thirty and fifty years, being 
rare before twenty and after fifty-five. Gusserow, out of 919 cases of 
fibroids, found only 15 under twenty years of age and only 17 over 



Le/f tube. 



Left ovary 




~Righlfoyarij 



Fig. 105. — Diagram Showing an Intraligamentous Fibroid. 

sixty years of age. The highest percentage, 38. 8, was between the 
ages of thirty and forty, and the next highest, 36.7, was between 
forty and fifty. Fibroids are undoubtedly very frequenl in the 
negro race. The autopsy statistics of the Johns Hopkins Hospital 
show, according to Kelly and Cullen ("Myomata of the Uterus," 
1909), that out of 742 autopsies on white and black women, over 
twenty years of age, 20 per cent bad fibroids in their uteri, and oi 
these, 33.7 per cent of the black women had uterine myomata, and 
10 per cent of the white women were affected in this way. I' « 
not yet determined whether fibroids are more common among the 



250 DIAGNOSIS OF FIBROID TUMORS OF THE UTERUS 

single than the married. Bayle and other authors thought that 
they were, while Gusserow, Dupuytren, West, and others, hold that 
they are not. 

ETIOLOGY 

The causation of these tumors is even now unknown, although 
the problem has been studied assiduously by many noted investi- 




Fig. 106. — Large Submucous Fibroid showing Distortion of the Uterine 

Cavity. (Kelly.) 



gators during the last fifty years, and many hypotheses have been 
advanced, but so far none has been proved correct. An ingenious 
theory is that advanced by A. Claisse (These de Paris, 1900). He 
thinks they are due to infection of the uterine mucosa; subacute 
inflammatory lesions of the mucosa, especially about the little 
blood-vessels of the muscular wall, causing proliferation of round 
cells, which are transformed into fibrous tissue. Heredity has been 
supposed to play a part in the causation of fibroids; Hofmeier, 
Veit, Klein waehter, and others considering it a predisposing cause. 
It is doubtful whether this assumption is well founded, however, 
and we must regard the occurrence of fibroid tumors in members 



COURSE AND DEVELOPMENT 251 

of the same family — a not uncommon happening — as coincidences 
rather than examples of heredity. 

Sexual irritation, such as masturbation or abnormal sexual 
practices, has been assigned as a cause of myoma by Veit. While 
the chronic congestion which is due to undue irritation of the 
genital organs may assist the growth of a fibroid, it is difficult to 
see how it could originate one. It is probable that man}' fibroids 
are of congenital origin, perhaps due to a fetal misplacement of 
tissue according to Colmheim's theory, but, as already stated, 
this has not been proved. The tumors do not attain any con- 
siderable size until the late child-bearing period* therefore age 
must be considered a factor in the etiology. 



COURSE AND DEVELOPMENT 

The development of a fibroid is a slow affair, generally a matter 
of years. H. A. Kelly has cited a case which was under medical 
observation for twenty-five years before operation and two years 
after. (" Operative Gynecology," 1907, Vol. II, p. 347.) A large 
interstitial tumor, with a uterine cavity measuring eight or nine 
inches, became larger and subperitoneal and pedunculated so that 
at operation it was found attached to a small uterus by a pedicle 1 
centimeter long and 3 centimeters broad. It weighed 59 pounds. 

I have spoken of the direction of the growth in describing the 
different kinds of tumors. Upon the course taken by the tumor 
in its growth depends often its subsequent fate. For instance. 
if it grows subserous it may become pedunculated and in lime 
may be separated entirely from the uterus, receiving its nourish- 
ment through adhesions to surrounding structures. Such cases 
are rare, but are met with occasionally. If, on the other hand, the 
tumor grows toward the uterine cavity, it is apt to be extruded 
through the external os. In either case the blood supply to the 
tumor is interfered with and there 18 a tendency to necrosis and 
degenerative changes. If the tumor remains in the substance oi 
the uterus, as in the ease of an interstitial fibroid, its nourishment is 
established on a surer footing. It is possible for all tumors and 
for small tumors especially, to remain in a quiescenl state for an 
indefinite period. Bland-Sutton ("Tumours Ennocenl and Malig- 
nant," 4th Edition, 1900, p. 1ST: calls attention to the latent seedling 



252 DIAGNOSIS OF FIBROID TUMORS OF THE UTERUS 

fibroids, in regard to which he says: "If a number of uteri be ex- 
amined from women between the twenty-fifth and fiftieth years by 
the simple means of sectioning them with a knife, in a large propor- 
tion of these uteri a number of small rounded fibroids, resembling 
knots in wood, will appear, their whiteness being in strong contrast 
with the redness of the surrounding muscle tissue. These discrete 
bodies, in many instances no larger than mustard seeds, are in 
histologic structure identical with the fully grown tumours." 




Fig. 107. — Pedunculated Fibroid Originating in the Cervix that has been 
Expelled into the Vagina. (After Auvad.) 



When removing fibroids by operation one can never be sure that 
all tumors have been removed; therefore, a patient can not be 
assured that the fibroids will not grow. On the other hand, 
tumors may increase rapidly in size. Soft tumors grow faster 
than hard ones, as a rule. Fibroid tumors grow during pregnancy 
and diminish in size markedly after delivery. They increase in 
size just before each menstrual period and diminish after the flow 
has ceased. In many instances they lessen in size after the meno- 
pause, but not always. All these facts must be kept in mind when 
examining a patient at different times to determine the relative 
bulk of a tumor. 

DEGENERATIONS 

There are certain alterations of structure occurring in fibroids, 
the causes of which we do not know, except that sometimes they 
can be explained by the presence of arteriosclerosis and a diminished 
blood supply. Degenerations in fibroids are observed frequently 
following pregnancy. An increased formation of fibrous and hya- 



DEGENERATIONS 253 

line tissue occurs in practically all myomata and, when the pn 
is extensive, necrosis of the center occurs, with a resulting cyst 
cavity with walls of irregular outline. 

Softening of a fibroid tumor may be due to several causes. 
Among them we may enumerate hyaline, colloid, and fatty de- 
generation. 

Hyaline degeneration was noted in 3.1 per cent of 2,274 cases 
of fibroid tumors collected by Noble from the literature ("Gynecol- 
ogy and Abdominal Surgery," H. A. Kelly and C. P. Noble, 1907, 
p. 669). Often these tumors become progressively indurated, 
especially after the menopause. 

Colloid or Myxomatous Degeneration. — This is characterized by 
the effusion of mucous material between the muscle bundles, the 
mucin and proliferation of round cells in the interstitial tissue 
distinguishing it from edema. Noble found myxomatous degen- 
eration in 3.4 per cent of his 2,274 cases. 

Small, hard tumors are found at autopsies on old women, their 
presence not having been detected during life. 

Fibro-cystic Tumors. — These tumors result from the breaking 
down and liquefaction of areas of degeneration in fibroids and the 
fusion of different foci by the absorption of the dividing partitions. 
The degenerated areas are separated, not by distinct walls, but by 
portions of the fibrous structure of the tumor. These tumors are 
not, as formerly thought, a separate class of tumors. 

Doleris (Archiv. de tocologie, janv. et fev., 1883, pp. 1 and 364 . 
noted a proliferation of connective tissue becoming colloid in a 
fibroid tumor during pregnancy. After delivery it is supposed 
that the diminution in the size of a fibroid is due to fatty degen- 
eration. 

Calcification. — This is rather a rare transformation which Noble 
(loc. cit.) found in 1.7 per cent of his cases. Deposits of phos- 
phate and carbonate of lime are found near the periphery of the 
center of the tumor and make either a- bony framework net true 
bone, however— or a shell. Rarely is the tumor solidified to 
make the so-called "uterine stone." Small areas of calcification 
are not uncommon. 

Fatty Degeneration. Gusserow ("Die Neubildungen d 
rus," 1886) has called attention to the fact thai fatty degeneration 
of a fibroid tumor has been determined microscopically in only three 



254 



DIAGNOSIS OF FIBROID TUMORS OF THE UTERUS 



cases — those of Freuncl, A. Martin, and Brunings — where there has 
not been resulting diminution in the size of the tumor as well. 
There is a form of fibroid tumor called lipomyoma in which a por- 
tion of the tumor is composed of fatty tissue. 

Edema. — Edema is often present in fibroids and may be con- 
sidered a beginning stage of necrosis. It most often affects the 
subserous tumors. 

Amyloid Degeneration. — A single case of amyloid degeneration 




Fig. 108. — Fibroid of the Cervix Distending the Vagina. (After Dartigues.) 



of a fibroid polypus has been observed by Stratz. (Zeit. f. Geburts. 
u. Gyn., 1889, Bd. XVII., H. 1, p. 80.) 

Suppuration. — This is the result of the infection of the tumor 
with bacteria derived from the intestinal canal, the genital tract, 
or the blood. Prolonged pressure of a tumor on the bowel, or an 
appendix vermiformis adherent to the tumor, may permit easy 
penetration of microorganisms. Instrumental or digital invasion of 
the uterine cavity for exploration or curetting may infect a fibroid, 
(Specially a submucous myoma. 

Gangrene. — Gangrene may result when a tumor is undergoing 
degeneration, or when there is torsion of its pedicle. Micro- 



COMPLICATIONS 255 

organisms may or may not play a part in the necrobiotic proi 
The mechanism of the process is obscure. Extreme torsion of a 
tumor, causing stasis of the blood supply and necrosis or gangrene, 
is a rare complication of fibroid tumors. Zangemeister thought 
that the fibroid uterus when rotated showed commonly (21 times 
to 3) a torsion to the right side. 

Thrombosis. — Thrombosis of the blood-vessels of a fibroid may 
occur. It is probable that the tumor is tolerated in the body for 
a long time after the blood supply is cut off before it becomes in- 
fected, just as in cases of neglected extra-uterine pregnancy in the 
late months. 

Sarcomatous Degeneration. — This occurred in two per cent of the 
cases collected by Noble {loc. tit.), and Winter (Z tits, filr Geburts. 
und Gynakol., Bd., LVIL, H. 1, 1906, p. 19) found sarcoma in 
4.3 per cent of 253 cases of fibroid tumor in which sections were 
taken systematically from different parts of all tumors. 

COMPLICATIONS 

Carcinoma occurs as an associated lesion in fibroid tumors, not 
as a degeneration, for we know that the two processes are distincl 
histologically, with the exception of a few cases of adenomyoma 
where cancer has been described as springing direct from the 
glands within the tumor. In a study of 4,880 consecutive cases 
of fibroid tumor, Noble (loc. tit.) found that cancel- was present in 
2.8 per cent. In his personal experience with 337 fibroids, cancer 
of the corpus was present in 2.6 per cent, and cancer of the cervix 
in 1.4 per cent; hence, as women not the subject of fibroid tumor 
have cancer of the cervix ten times to one for cancel- of the corpus 
uteri, he concluded that there is a causal relation between fibroma 
and cancer of the body of the uterus (adeno-carcinoma of the 
endometrium). 

Metastases. — Fibroid tissue can be invaded and destroyed by 
an epithelial growth. The most frequent combination is occurrence 
of carcinoma of the body of the uterus coincident with fibro-myoma. 
Sometimes a fibroid tumor includes in its tissues glandular elements 
derived from the ducts of Mi'illcr or Wolff, and these elements mo 1 
subject to a carcinomatus transformation. X. Bender and ( 1. 
Lardennois (Bull. Soc. Anat., L904, No. 8, Octobre) have shown 



256 DIAGNOSIS OF FIBROID TUMORS OF THE UTERUS 

that uterine fibroids may be invaded by metastases from cancer 
of some distant organ. 

Diseases of the Tubes and Ovaries. — These diseases, due to infec- 
tion, are not infrequent complications of fibroids. Daniel studied 
this subject in Pozzi's clinic (C. Daniel, Rev. de gyn. et de chir. 
abd., 1903, pp. 25 et 193). In most cases either the ovaries, or 
the tubes and ovaries together were diseased, rarely the tubes 





w 




Fig. 109. — Large Globular Fibroid, the Lower Part Filling the Cavity of the 
Pelvis, Simulating Pregnancy at Term. (Kelly.) 

alone were affected. Among 139 cases gathered from the litera- 
ture in addition to his own cases he found lesions of the tubes 32 
times, alterations of the ovaries alone 79 times, and tubo-ovarian 
disease 28 times. Among 70 cases observed in Pozzi's clinic the 
most common lesions were catarrhal salpingitis, purulent salpin- 
gitis, hematosalpinx, and cystic degeneration of the ovaries. In 
Noble's 2,274 cases of fibroid tumor (loc. cit., p. 668), complications 
in the uterine appendages or in the pelvis existed in 37 per cent. 
In Pozzi's clinic lesions of the tubes and ovaries occurred in 59 
per cent of the myoma cases. 



EFFECT OF FIBROID TUMORS 257 

In the analysis of these statistics it is not to be forgotten, how- 
ever, that these large percentages were among women whose 
fibroid tumors required surgical treatment; they had entered the 
hospital for operation. It is hardly fair to assume that all fibroids 
are subject to complications to the same extent; in fact, this is an 
objection to most of the statistics which have to do only with 
fibroid tumors causing symptoms of a severe grade. 



EFFECT OF FIBROID TUMORS UPON NEIGHBORING ORGANS 

The uterus, being attached to the vagina, to the uterine liga- 
ments, and to the peritoneum, is more or less limited in its move- 
ments. If a fibroid tumor develops in its substance, the uterus 
may displace the bladder or press the rectum, urethra, or ureters 
against the bony framework of the pelvis. In the case of a fibroid 
of the posterior uterine wall, the cervix may press on the urethra 
and cause retention. But this is a rarity. The bladder is extremely 
tolerant to misplacement by a tumor. However, retention is sonic- 
times caused in this way, and congestion of the vesical mucosa, 
which exists in the case of fibroids as determined by Zukerkandl 
through cystoscopic examinations (A. Yenot, Annales de gyi 
d'obstet, 1907, 2 s., IV., 287-310), furnishes a favorable soil lor the 
growth of bacteria that may be introduced by a catheter. Injury 
of the ureters and kidneys from pressure on the ureters i- much 
more frequent than thought formerly. Knox has reported a series 
of cases of compression of the ureters observed during operation 
on fibroids at the Johns Hopkins Hospital. Of the different vari- 
eties intraligamentous growths and tumors developing from the 
cervix are most apt to compress the ureters and also to displace 
them upward. 

It is difficult to say even approximately just what is the fre- 
quency of renal disease because of ureteral compression by fibroid 
tumors. J. C. Webster found renal complications due to fibroids 
in 30 per cent of 100 cases on the other hand. Haultain in L20 
cases had never met renal complications. Cullingworth me1 hydro- 
nephrosis due to compression in 2 out of ion cases: Sarwey, 1 in 
130 cases: Knox. :; in ion. A. Venol points out that the com- 
pression of the ureter is probably intermittent, due t<> the motion 

17 



258 DIAGNOSIS OF FIBROID TUMORS OF THE UTERUS 

of the fibroid ; therefore .symptoms due to the compression are not 
present with any definite regularity. 

Interference with defecation due to pressure on the rectum by 
a fibroid tumor is a common complication. 

Tumors situated low cause the greatest degree of interference 
with the enlargement of the uterus during pregnancy and with 
delivery. Fibroids, then, are a cause of abortion. Lefour (These 
d'agreg. de Paris, 1880), out of 307 cases of pregnancy compli- 
cated by myomata, noted 39 abortions (12.7 per cent), the mother 
dying in 14 cases. Nauss (These de Halle, 1882), out of 241 
cases, found that abortion took place in 47, or 15 per cent. The 
tumors situated low in the pelvis obstruct delivery; if situated 
elsewhere in the substance of the uterus they generally interfere 
with involution and are the cause of post-partum hemorrhages. 
Although the presence of a fibroid is by no means a bar to the 
occurrence . of pregnancy, it is a frequent cause of sterility. Ols- 
hausen gathered the statistics of nine different observers, including 
Scanzoni, von Winckel, Schroeder, and Hofmeier, and found that 
out of 1,731 married women with fibroid tumors 520, or 30 per cent, 
were sterile. He considers this figure too high, however, because 
many women with fibroids come under a physician's observation 
only because of sterility, and those who become pregnant often do 
not consult a physician at all. 

EFFECT ON DISTANT ORGANS AND ON THE SYSTEM 

Anemia from prolonged and repeated hemorrhages is one of the 
most common results of fibroid tumors. The hemoglobin may be 
reduced as low as thirty per cent or even less and the red cells to 
1,000,000. The affection is a serious one and difficult to correct 
often, even after the drain of blood has been stopped. Acute 
hemorrhage in fibroid cases seldom proves fatal, but the continued 
loss of blood produces a condition of lowered vitality, and a dis- 
position to thrombosis, embolism, and phlebitis that counter- 
indicates in many cases an operation for the removal of a tumor. 
Many authors state that the hemoglobin should be at least fifty 
per cent before a hysterectomy is undertaken. Kelly and Cullen 
however, (loc. tit., pp. 453 and 454), report twenty-two cases of 
operation for the removal of myomata in which the hemoglobin was 



RELATION OF FIBROID TUMORS TO HEART DISEASE 259 

forty per cent or less ; with a mortality of three cases. It often hap- 
pens that several years elapse before a profoundly anemic patient 
regains good health after the cause of the loss of blood has been 
removed. 



RELATION OF FIBROID TUMORS TO HEART DISEASE 

The frequency of cardiac palpitation in fibroid tumors has been 
referred to by me. (Amer. Jour. Obstet., Vol. XXIX., No. 3, 1894.) 
The symptom appears to be quite independent of actual cardiac 
disease, there being no evidences of enlargement of the heart or 
of adventitious murmurs. It is possible that palpitation may be 
due to anemia, in which event one expects to find hemic murmurs, 
and some influence must be assigned to the menopause in patients 
who are in this time of life. (See Chapter XXIX., page 613.) 
The exact relation of these tumors to heart disease is not known. 
Certain degenerative changes in the heart and in the blood-vessels, 
such as brown atrophy, fatty degeneration, fatty infiltration of the 
heart muscle, also chronic endocarditis, and arteriosclerosis of the 
arteries have been noted by students of this question, notably by 
Hofmeier, Fenwick, Strassman and Lchmann, Boldt, Pellanda, Win- 
ter, and Fleck, as quoted by Noble (loc. cit., p. 671). Winter found 
the heart perfectly normal in 60 per cent of 266 case- examined 
with reference to this point; valvular disease was found in but 1 
per cent, and dilatation and hypertrophy in but 6 per cent, the 
examinations being made in every case by a specialist in interna! 
medicine. 

It is difficult to understand how lesions of the heart can be 
caused by tumors. I think we may agree with Winter that, in 
the present state of our knowledge, we must attribute almosl all 
of the cardiac symptoms in cases of fibroid tumors to anemia, and 
consequent derangement of the nervous system. It is well to re 
member, however, that heart disease nol infrequently accompanies 
fibroids, although not necessarily in a causal relation. 



260 DIAGNOSIS OF FIBROID TUMORS OF THE UTERUS 



DANGEROUS TO LIFE 

Fibroid tumors may be a direct menace to life. Pellanda (C. 
Pellanda, "La Mort par Fibromyomes Uterins," Paris, 1905), in a 
study of 171 cases of death from fibromyomata without operation, 
states that in 6.4 per cent of the fatal cases death was clue to 
hemorrhage. 

Acute abdominal emergencies due to torsion and infection of a 
tumor are by no means unknown. Rupture of the uterus, due to 
fibroids obstructing labor, has occurred. As a rule, however, 
these tumors endanger life indirectly through their degenerations 
and complications, through interference with the function of other 
organs, and by their effect on the general health — anemia and its 
consequences. 

SYMPTOMS 

The symptoms of fibroid tumors are hemorrhage, anemia, pain, 
and leucorrhea, also constipation, frequency of micturition, reten- 
tion of urine, and dysuria; the last four being the result of pres- 
sure on rectum, ureters, urethra, or bladder. 

Hemorrhage. — Hemorrhage may be of the type of menorrhagia 
or of metrorrhagia, more often the former. It is a symptom met 
with in the submucous tumors, occasionally in the interstitial, and 
not at all in the subserous. As most fibroids are multiple it is 
not always easy to say which form predominates in any given 
case. The submucous varieties cause hemorrhage by enlarging 
the surface of the endometrium, the total number of square inches 
being increased many times in the case of large tumors. 

Diapedesis of red blood cells through the walls of the capillaries 
of the endometrium takes place to a greater extent the larger the 
surface involved, but venous congestion caused by the pressure 
of the tumor on the thin-walled veins is supposed to be at the root 
of the mechanism of hemorrhage in fibroid tumors ; the arteries, 
with their thicker, elastic walls, being able to withstand better the 
pressure. The flowing may be only slightly increased over normal 
or it may amount to an excessive hemorrhage requiring active 
treatment. The size of the tumor bears no relation to the amount 
of the flow, the small tumors often having the greatest flowing. 



SYMPTOMS 26] 

It is a curious fact that some women with fibroids flow more when 
they are lying down than they do when up and about; therefore 
the treatment in such cases is not rest in bed. This* peculiarity 
should be looked for in getting the history. An active acute 
hemorrhage is generally not so serious in its effects on the system 
as a lesser bleeding lasting over months and years. 

Anemia. — Anemia exists so frequently in fibroid tumors that the 
physician should be on the lookout for a pale face, lips without 
much color, eyes a pearly white, muscles rather flabby, pulse 
bounding, but soft and compressible, with increased rapidity on 
the slightest excitement. Besides palpitation a feeling of faint- 
ness and breathlessness and languor accompanies anemia. In some 
cases there is swelling of the ankles. The red blood cells may fall 
to one-fifth or less of the normal number (1,000, 000 per cubic 
millimeter), and the hemoglobin to thirty per cent. Hemic heart 
murmurs are usually present. 

Pain. — Pain may or may not be present in fibroid tumors, and 
when it does occur is variable in amount. It is either referred to 
the uterus or to other organs when due to pressure on surround- 
ing structures. It assumes several forms, occurring as a dull, con- 
stant pain situated in one or both groins or across the abdomen, 
as a bearing-down pain, or as a backache, and these varieties may 
exist separately or conjointly. It may be referred to the thighs or 
the legs in consequence of the pressure of the tumor on the sacral 
plexus of nerves. Pressure on a ureter may cause pain, but the 
rectum and bladder arc generally tolerant of pressure so far as pain 
is concerned, their disturbance when pressed upon showing itself 
in derangement of function. Dysmenorrhea occurs in about twenty 
per cent of the cases of fibroid tumors, the cramp-like pain being 
often severe. It must be remembered, however, thai an uncom- 
plicated fibroid rarely gives rise to much pain, and therefore the 
presence of pain, especially if ^vcrc, indicates an inflammatory 
complication, such as salpingitis or adhesions. A rapidly grow- 
ing tumor is apt to cause pain which is referred to the uterus. 
Expulsive pains are found when a submucous tumor becomes 
pedunculated and can be extruded either in pari or wholly ai the 
external os. Kelly and Cullen found that tumors of moderati 
caused the most pain. 

Leucorrhea. — A vaginal discharge is rare in fibroids excepl in 



262 DIAGNOSIS OF FIBROID TUMORS OF THE UTERUS 

the submucous variety. In this form it is common as a white 
discharge, and if the tumor is necrotic the discharge is muddy, 
watery, and malodorous. A profuse watery discharge associated 
with fibroids should always excite suspicion of cancer. 

Symptoms of Adenomyoma. — According to Cullen this variety 
of myoma is most prevalent between the thirtieth and sixtieth 
years and does not tend to cause sterility. Lengthened menstrual 
periods are the first symptoms and the flowing gradually assumes 
the proportion of hemorrhages. There is pain with the period 
that is referred to the uterus; it may be grinding in character. 
There is no intermenstrual vaginal discharge and microscopical 
examination of scrapings shows the uterine mucosa to be normal. 



DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS 

The diagnosis of large fibroid tumors is a comparatively easy 
matter, but the diagnosis of small ones is often difficult. The 
symptoms are not of much assistance, except that painful menstru- 
ation becoming profuse and protracted, and a history of sterility 
or early miscarriages, are suggestive of fibroids. The chief reliance 
is the bimanual palpation ; and the passage of the uterine sound is 
most useful. The first point to determine is the relation of the 
tumor mass to the body of the uterus. 

Subserous Fibroid Tumors. — If the tumor is a single mass bi- 
manual palpation shows that it is connected with the uterus. 
To determine this point place the tip of the forefinger in the vagina 
on the cervix. On moving the tumor with the other hand on the 
abdomen, note whether the cervix moves at the same time. Out- 
line the growth as exactly as the laxity and thinness of the ab- 
dominal walls will permit. In some cases of small-sized tumors in 
women with thin parietes, it is possible to map out the ovaries, 
and an attempt should be made to do this in every case. If the 
tumor is pedunculated it must be differentiated from an ovarian 
cyst This is done by detecting fluctuation in a cyst. Making 
firm pressure against the tumor with the finger in the vagina, taps 
with the finger of the hand on the abdomen are transmitted to 
the finger in the vagina as waves. The pedicle of a pedunculated 
myoma may be palpated by drawing down the cervix with a 



DIAGNOSIS AND DIFFERENTIAL DIAGN< 

vulsellum, which is passed to an assistant to hold while the bi- 
manual recto-abdominal touch is practised. (See Fig. 12G. page 
301.) If the contents of the cyst are thick and semisolid, as in the 
case of dermoid cysts, the fluid waves will be absent. Some ova- 
rian cysts are as hard as some fibroids, especially soft fibroids. 
As a rule the fibroids are multiple and there is more than one 
nodule to be reckoned with; not only that, but the nodules are 
usually of a stony hardness. If the fibroid tumor or tumors are 
large enough to distend the abdomen the uterus is drawn up in the 
pelvis. This upward excursion of the uterus does not take place in 
the case of an ovarian turmor. 

Fibroma of the ovary has been mistaken for a pedunculated 
subserous fibroid. Here only an abdominal operation can clear up 
the diagnosis. The sound should be passed. Fibroids are so often 
multiple that a lengthened canal may indicate a submucous or an 
interstitial fibroid and therefore indirectly point to a subserous 
tumor. Before passing the sound observe strict antiseptic precau- 
tions and always inquire as to the elate of the last menstrua- 
tion. 

Pelvic inflammatory exudate may complicate a fibroid tumor, but 
is seldom mistaken for it. The mass in inflammation is brawny and 
fills in the chinks of the pelvis. There is a history of fever, even 
if it is not present at the time, as shown by the thermometer. 

Cancer of the pelvis, originating in the uterus or ovaries, may be 
mistaken for fibroid tumor, but is differentiated by the fixity of 
the infiltration, and the lack of definite outline of the tumor. 

Ascites is occasionally present in large tumors. Change of posi- 
tion of the patient changes the situation of the fluid, which is 
mapped out by its flatness to percussion. 

The contour of the abdomen in the case of large fibroids is dome- 
shaped if the fibroid is globular and single, nodular if multiple. 
The tumor stands out sharply on all sides when seen in profile. 
(See Fig. 103.) Ascites, if it is present in excess, modifies the contour. 

Intraligamentous Fibroid Tumors.— An intraligamentous fibroid 
is situated at one side of the uterus, the sound showing the situa- 
tion of the latter if it can not be palpated. This sort <>!' tumor is 
low in the pelvis, often ii can be felt projecting into the v.-r 
Its mobility is limited because of it- attachments an<l it- situation. 

Interstitial Fibroid Tumors.— The uterine canal is commonly 



264 DIAGNOSIS OF FIBROID TUMORS OF THE UTERUS 

lengthened in cases of interstitial fibroids, and hemorrhage is likely 
to occur in these tumors. In this variety the enlargement of the 
uterus may be symmetrical, or it may be asymmetrical. In the lat- 
ter, the diagnosis is easier to make; in the former, one must rule 
out pregnancy. To do this it is important to get the history most 
carefully, having regard to amenorrhea and nausea. The elastic 
feel of the pregnant uterus is to be sought for, also the softening of 
the cervix and the bulging of the anterior segment early in preg- 
nancy and ballottement later. (See Chapter XXII., p. 423.) 
Breast changes are to be looked for, and if the tumor is large an 
attempt should be made to auscult the fetal heart sounds. An- 
other examination a month later will confirm a diagnosis of preg- 
nancy. 

A fibroid rarely becomes cystic before it has attained the size of 
a three months' pregnancy; therefore, an elastic tumor of less 
than this size is probably not a fibroid. The sound is not to be 
passed if there is the slightest suspicion of pregnancy. Examina- 
tion under ether is advisable if the abdominal walls are tense or 
the conditions for examination are not entirely satisfactory. 

Sarcoma may develop in a fibroid. In this event the tumor has 
grown rapidly. Only operation makes a positive diagnosis of sar- 
coma. 

Submucous Fibroid Tumors. — A history of hemorrhage is present 
in almost all submucous fibroids. Here the diagnosis is established 
by the sound and, if necessary, by digital exploration of the uterine 
cavity. Bimanual palpation determines an increase in size of the 
uterus. This is true even in the case of small growths. The 
sound shows enlargement and distortion of the uterine cavity. 
If the tumor is at the fundus nothing but digital exploration will 
settle the question whether it is sessile or pedunculated. Some- 
thing may be learned often by the tactile sense transmitted through 
the exploring sound. To make a digital exploration of the uterine 
cavity the cervix is to be dilated by a series of dilators: the Hanks, 
followed by the Wathen or by large Simon dilators, plenty of time 
being taken so that rupture may not occur. In cases of hard, 
resistant cervices it is best to adopt the method of incision of the 
anterior wall of the cervix described in Chapter VII., page 94, 
repairing the cervix by suture after the exploration is finished. A 
sessile submucous fibroid of the fundus uteri may be mistaken for 



DIAGNOSIS AXD DIFFERENTIAL DIAGNi 

adenoma or adeno-carcinoma. A piece removed and submitted 

to microscopic examination is the only means of distinguishing 
the two. A pedunculated tumor presenting at the externa] os may 
be mistaken for inversion and, if sloughing, for cancer of the cervix. 
It is distinguished from cancer by learning that the sound may 
be made to sweep entirely around the tumor, thus making sure 
that the cervix itself is not the seat of the disease: and from inver- 
sion by noting, by bimanual recto-abdominal touch under ether, 
that the fundus uteri is in its normal situation. An inverted 
uterus is usually very sensitive to touch, although not invariably so. 
Cancer of the body of the uterus and cJiorioepitJielioma are to be 
excluded by the examination of tissue removed from the uterine 
cavity by curetting or by digital exploration, and, in the (-a-'' of 
chorioepithelioma, by the history of a previous labor, abortion, 
or hvdatidiform mole having occurred within a few weeks. 



CHAPTER XVI 

THE DIAGNOSIS OF MALIGNANT DISEASES OF THE 

UTERUS 

Cancer, Sarcoma, and Malignant Chorioepithelioma 

Cancer of the uterus, p. 266: Definition, p. 266. Varieties, p. 266. 
Diagnosis of cancer of uterus in general, p. 270. Diagnosis of cancer of the 
cervix, p. 271; Differential diagnosis of cancer of the cervix, p. 272. 
Diagnosis of adeno-carcinoma of the cervical canal, p. 275; Differential 
diagnosis of the adeno-carcinoma of the cervical canal, p. 276. Diagnosis 
of cancer of the body of the uterus, p. 276; Differential diagnosis of 
cancer of the body of the uterus, p. 277. 

Sarcoma of the uterus, p. 278: Frequency and definition, p. 278. 
Varieties, p. 279. 

Malignant chorioepithelioma, p. 280: Definition, macroscopic and mi- 
croscopic appearances, p. 280. Course of the disease, p. 281. Ectopic 
malignant chorioepithelioma, p. 282. Diagnosis, p. 283. 



THE DIAGNOSIS OF CANCER OF THE UTERUS 

By cancer of the uterus we understand a malignant new growth 
the essential elements of which consist of epithelial cells having a 
characteristic arrangement. The cancer cells may proliferate and 
directly invade the surrounding tissues or they may be transported 
by the lymphatics to distant sites and there proliferate and form 
metastatic growths. 

Varieties 

The mucous membrane of the uterus may be divided into three 
types: (1) That covering the vaginal portion of the cervix, extend- 
ing from the vaginal vault to the external os, and composed of 
squamous-celled epithelium. (2) That lining the cervical canal 
from the external os to the internal os, and composed of high 
cylindrical epithelial cells; and (3) That lining the uterine cavity 
proper from the internal os to the fundus, and composed of low 

266 



CANTER OF THE UTERUS 



261 



cylindrical or cuboidal epithelial cells. Cancer of the uterus al- 
ways originates in the mucous membrane, and the type of cancer 
is determined by the character of the cells of the mucous mem- 
brane in which it originates. 
We have then three kinds of cancer of the uterus: 

1. Squamous-celled cancer of the cervix. 

2. Adeno-carcinoma of the cervical canal. 

3. Adeno-carcinoma of the body of the uterus. 




Fig. 110. — Early Stage of Squamous-celled Cancer of the Cervix. The Cauli- 
flower Mass has been Curetted away. (Cullen. 



Very rarely there is present a squamous-celled cancel- of the 
body of the uterus. 

1. Squaynous-celled cancer of the cervix begins at or near the junc- 
tion of the cervical and vaginal mucous membranes at the external 
os. Clinically, three types are recognized: (a) The everting or 
cauliflower growth, in which there is marked proliferation of the 
cancer, the growth spreading to and involving by direct extension 
the vault of the vagina. (6) The infiltrating type, in which the 
external contour of the cervix may remain normal, the growth 
extending internally deep into the wall of the cervix, (c rhe 
ulcerative type, in which ulceration with loss of cervical tissue takes 
place early and proceeds until the entire cervix is eroded. 



268 DIAGNOSIS OF MALIGNANT DISEASES OF THE UTERUS 

The squamous-celled type of cancer of the cervix is usually of 
rapid growth and it soon involves the surrounding tissues and 
organs — the bladder, the ureters, and rectum. The lymph glands 
of the parametrium and the iliac glands receive the cancer by 
means of the lymph channels and themselves take up the disease. 

Microscopically the squamous-celled type begins as an hyper- 
trophy of the pavement squamous epithelium of the cervix. The 
cells themselves hypertrophy and have large round or oval vesic- 
ular nuclei with many mitotic figures. These cells invade the 




Fig. 111.— Very early Adeno-Carcinoma of the Cervical Canal. (Cullen.) 

cervical tissue in all directions and without any typical arrange- 
ment. 

2. Adeno-carcinoma of the cervical canal originates in the high 
cylindrical epithelial cells lining the cervical canal and the glands 
of the cervical canal. This t}^pe of cancer of the cervix spreads 
perhaps less rapidly than the squamous-celled variety, although 
necrosis takes place rather early. The squamous-celled variety 
seldom spreads beyond the level of the internal os, but the adeno- 
carcinoma frequently reaches to the fundus. The cervix may be 
reduced to a mere shell by the necrosis of the latter form of cancer 
and yet the external contour of the cervix remains unchanged. 
Metastasis to the surrounding organs, the bladder and rectum, 



CAXCER OF THE UTERUS 



269 



takes place usually by direct extension of the growth. The iliac 
glands are involved sometimes early and sometimes late, as is the 
case with the squamous-celled variety. 

Microscopically adeno-carcinoma of the cervix is recognizee! 

as a proliferation of the cylindrical cells of the cervical mucous 
membrane, these cells preserving their alveolar or glandular ar- 
rangement. There is distinct loss or crowding out of the inter- 
glandular stroma, the proliferating alveoli lying close to one another. 
3. Adeno-carcinoma of the body of the uterus originates in the 
low columnar epithelium lining the uterine cavity and the glands 




Fig. 112. — Early Adeno-Carcinoma of the Body of the (Jterui 



Cull. 



of the endometrium. It usually starts at the fundus or in one 
cornu as a circumscribed area of proliferation of the endometrium. 
From this point it may spread until it involves the entire uterine; 
cavity. The growth may proliferate, forming actual outgrowth* 
of endometrium into the uterine cavity, as well as invade the 
uterine muscular wall. The growth may ulcerate it- way thro 
the uterine wall and appear in the peritoneal cavity and form 
peritonea] metastases. This is generally a late process of a 
existing cancer. The ordinary benign uterine polyp, I" ereil 

by endometrium, may become carcinomatous. Adeno-carcin 



270 DIAGNOSIS OF MALIGNANT DISEASES OF THE UTERUS 

of the body seldom extends beyond the internal os, although adeno- 
carcinoma of the body and cervix may coexist. 

Glandular metastasis from this form of cancer is late. 

Microscopically adeno-carcinoma of the body is recognized by 
the proliferation of the low cylindrical cells of the endometrium 
of the fundus, these cells preserving their glandular arrangement 
with distinct loss of interglandular stroma. The cells lining the 
new glands are from two to four layers deep or possibly entirely 
fill the alveolus. 

Diagnosis of Cancer of the Uterus in General" 

It is important to keep in mind that cancer is always a local 
disease in the beginning and that prompt removal of the diseased 
tissues effects a permanent cure ; therefore early diagnosis is espe- 
cially important. A failure to make a correct diagnosis is followed 
surely by the death of the patient in from six months to a year 
and a half. Late operations, except in the case of cancer of the 
body, are of value only in prolonging life a few months or a year 
or two, and in lessening suffering. The view commonly held by 
the laity, and, sad to relate, by too many of the medical profession, 
that cancer is an incurable disease is not true, provided that it 
can be recognized and removed before it has gained a good head- 
way. 

It appears that progress is being made in getting patients to 
submit to examination at earlier periods of the disease. G. Win- 
ter's works in spreading a propaganda, both among the physicians 
and the laity, in East Prussia, is most encouraging (Zentralblatt fur 
Gynakologie, 1904, No. 14, p. 441). It is a fact, however, that at 
the present time a large proportion of the sufferers from this dread 
disease are permitted to get into an absolutely hopeless state, then 
to go through the awful months of suffering until a lingering death 
releases them. 

The symptoms of uterine cancer are by no means pathognomonic ; 
they are suggestive and are as follows: Bleeding, particularly in 
women who have passed the menopause; and hemorrhage or a 
show of blood after coitus, also a persistent or recurring sero- 
sanguinolent vaginal discharge. Neither of these is a symptom 
of the normal menopause, as has been maintained in the past. The 



CANCER OF THE UTERUS 271 

menopause has no local symptoms if the uterine organs arc normal. 
Bleeding or a vaginal discharge occurring at the time of change of 
life should lead at once to a vaginal examination to determine the 
cause. Pain and cachexia are symptoms of the advanced, hope- 
less stages of the disease, only at this time one does not have to be 
a physician to make a diagnosis. Although the disease occurs 
most commonly in women who are between the fortieth and fiftieth 
years it may occur at any age between eight and seventy-six. 

Clinically, heredity seems to play a role, though this has been 
disputed. 

The disease is relatively rare in the colored race. 

It is more frequent among women who have borne children than 
in nulliparae. 

The diagnosis varies with the progress of the disease, and the 
variety of cancer present; the early stages, while the normal tissues 
are being replaced by cancer cells, show only a slight local thicken- 
ing or proliferation; the later stages, when the tissues are breaking 
down and degenerating, show ulceration, bleeding, and detritus 
with foul odor. 

As has been pointed out in describing the different forms which 
cancer assumes, the disease advances in different manners and at 
different rates of speed in individual cases. It may progress to a 
fatal termination in a year; on the other hand, I have had a patient 
who had the erosion type of cancer of the cervix where there was 
every indication that the disease had existed for twenty years. 
The tissues may be brittle and easily disintegrating, or tough and 
hard. The tissues most commonly Invaded by the differenl kinds 
of cancer have been noted, therefore in making a diagnosis the 
routes of extension of the disease must be taken into account. 
We employ both touch and sighl in makings diagnosis, as well 
as microscopic examination of tissues removed. 

Diagnosis of Cancer of the Cervix 

This, of all forms of uterine cancer, Is the easiesl of diagnosis 

because the lesions can be detected by both touch and sight. 

(a) The cauliflower growth is the simplest, growing as h -I'" 
a polyp-like mass projecting from the cervix into the vagina. In 
the early stages this appears a- an indurated, reddened area raised 



272 DIAGNOSIS OF MALIGNANT DISEASES OF THE UTERUS 

above the surrounding mucous membrane. In its later progress 
one expects to find a larger tumor, recldish-gray in color, with 
softened, disintegrated tissue. The sound perforates it with ease, 
and any manipulation causes hemorrhage. 

(b) If the infiltrating sort is present the tissues are indurated and 
the contour of the cervix may be altered or not. If the vaginal 
mucous membrane overlying the growth is intact the diagnosis 
is difficult. In all suspicious cases a wedge-shaped piece of tissue 
should be removed and submitted to the pathologist for micro- 
scopic examination. 

(c) The ulcerating variety is distinguished by an ulcer of exca- 
vating tendency. There is much loss of substance; the edges of 
the ulcer are rough and irregular; the base is necrotic; the under- 
lying tissues are hard to the feel. If portions of the deeper parts 
of the edge of an ulcer crumble on pressure by the ringer or sound 
the condition is suspicious of cancer; also, if the edge of the ulcer 
has a porky consistency and is of a yellowish-gray color. In all 
doubtful cases a piece of tissue must be removed for microscopic 
examination. To do this fix the cervix with a double tenaculum 
just outside the diseased area and let an assistant hold the tenacu- 
lum. If the cervix proves to be sensitive inject into the sound 
tissue surrounding the diseased area, in several places, a few minims 
of two-per-cent sterile solution of cocaine with a hypodermic 
syringe. Wait five minutes. With a single tenaculum and a 
scalpel or scissors cut out a good-sized piece of the diseased tissue 
in the shape of a wedge. Be prepared to place a catgut stitch 
with a curved needle should there be much bleeding. Often an 
application of tincture of iodine and carbolic acid followed by a 
dry tampon will be sufficient to stop all bleeding. The patient 
should not be dismissed until it is known that the bleeding has 
been controlled. 

Differential Diagnosis of Cancer of the Cervix 

(a) Cauliflower Form. — The cauliflower form of cancer of the 
cervix must be differentiated from: 

(1) Follicular hypertrophic polyp, 

(2) Mucous polyp. 

(3) Papillary tuberculosis. 



CANCER OF THE UTERUS 273 

(4) Myoma of the cervix. 

(5) Condylomata acuminata. 

(1) The follicular hypertrophies of the cervix produce discrete 
tumors, in some cases similar to polypi. They are soft, of a red 
color, and show the rounded, yellow, shot-like, dilated Nabothian 
follicles in their substance, the condition being not unlike that in 
the tonsil. The follicles may be seen and felt also in the surround- 
ing normal mucous membrane of the cervix. There is lacking the 
crumbling consistency, the sharp edges, and the indurated base 
of the cauliflower cancer. The microscope will confirm the diag- 
nosis. 

(2) Mucous polypi, especially if multiple and having a lumpy 
appearance, may be mistaken for cancer. Polypi are covered 
everywhere with mucous membrane, they are soft, and the sound 
will detect the position and size and shape of their pedicles. 

(3) Papillary tuberculosis, although relatively rare, may simulate 
closely polypoid carcinoma in its early stages. The external os 
may be surrounded by a papillary excrescence. It is possible in 
favorable cases to determine the presence of the little glassy tuber- 
cles the size of a millet seed lying in the greasy, cheesy substance 
characteristic of broken-down tuberculous tissue. In tuberculous 
disease of the cervix the ulcerated form is more common than the 
papillary. The diagnosis must be made by the microscope. 

(4) Myoma of the cervix is rare. A cervical myoma is covered 
with a smooth mucous membrane, it disintegrates by ordinary 
gangrene, and has a firm and not a crumbly consistency. 

(5) Pointed condylomata may simulate papillary cancer, especially 
during pregnancy. They form a circumscribed tumor of irregular 
surface; but they have no infiltrated base and no real ulceration, 
only a papillary surface with thick epithelium. They are of a 
reddish-white color. As a rule they occur in more than one Bitua 
tion at the sarin; time, i.e., on the wall of the vagina or Oil the vulva. 

(6) Infiltrating Cancer. Infiltrating cancer is confused mosl often 
with inflammatory diseases of the cervix occurring in connection 
with tears, especially when the tissues are indurated and nodular, 
as they often are. As a rule the inflammatory process involves 
the entire cervix, the consistency is not so hard as in cancer, and 
the external mucous membrane is qo1 involved. If the cervix is 
riddled with diseased Nabothian follicles the similarity of the two 

13 



274 DIAGNOSIS OF MALIGNANT DISEASES OF THE UTERUS 

conditions is often great. But here the cancer is limited, whereas 
the inflammatory affection is universal. In all cases a piece of 
tissue should be removed for examination. 

(c) Ulcerating Form. — The ulcerating form of carcinoma must be 
differentiated from: 

1. Erosion. 

2. Simple ulcer; as in prolapse. 

3. Tuberculous ulcer. 

4. Chancroids. 

5. Syphilitic ulcer. 

1. If there is very little infiltration and induration a cancerous 
ulceration may simulate a simple erosion, especially in those cases 
where the erosion has a thick, roughened surface. The character- 
istics of the malignant ulceration are to be borne in mind. Also, 
the erosion as seen through the speculum presents a bright red, 
shining appearance, while the cancerous ulceration shows loss of 
substance and a dull red or yellowish-gray color. 

The erosion has no sharp edge, but shows a gradual transition 
of the pavement epithelium of the normal mucous membrane to 
the erosion by a border of irregular outline, and there are apt to 
be islands of normal mucous membrane in the erosion. If there 
is infection of the erosion, scar formation results. In doubtful 
cases the microscope must be brought in. 

(2) Simple Ulcers. — These occur in prolapse; they are generally 
not situated at the external os, while the carcinomatous ulcers are 
more apt to be in that situation. They are apt to have a light 
yellow base and show cicatrization about the periphery, and there 
are islands of mucous membrane in the central portions. After 
the prolapsed uterus has been replaced for a day, all traces 
of infiltration of the tissues under such ulcers disappear and 
evidences of repair at the edges can be seen. As a rule there 
is little or no thickening of the tissues under these ulcers. This 
is the case also with ulcers caused by an ill-fitting pessary. They 
heal readily. 

(3) Tuberculous Ulcer. — This, although rare, is very similar to 
carcinomatous ulcer. Both are generally situated around the 
external os; the base of the tuberculous ulcer is yellow in color, 
nodular but not infiltrated. Yellow, miliary tubercles may be 
seen in the mucous membrane in the neighborhood of the ulcer. 



CANCER OF THE UTERUS 

There fs apt to be present also tuberculosis of the endometrium 
and of the tubes. The microscope settles the diagnosis. 

(4) Chancroids are generally small in size and multiple; their 
base has a diphtheritic, grayish appearance, and is not indurated, 
and the edges are indented and raised. Similar lesions arc to be 
found generally in the vagina and vulva. 

(5) Syphilitic ulcer may occur on the cervix in three forms: (a) 
as an ulcerated initial lesion, (b) as broken-down papules, or (c) as 
a degenerated gumma. 

(a) The initial lesion is solitary and of great hardness. The 
ulcer has a sharp edge and is of a dirty reddish-brown color: its 
discharge being of a greasy consistency. It may extend into the 
cervical canal in the case of a parous woman with open os externum. 

(b) Ulcers from papules are generally multiple and are elevated 
above the surrounding surface of the normal mucous membrane. 
Their surface is covered with disorganized white or yellowish tissue. 
Near them are to be found non-ulcerated papules, especially on 
the walls of the vagina and vulva. 

(c) Gummata of the cervix are very rare. They are described by 
Neumann (Winter's "Lehrbuch der Gynakologischen Diagnostik," 
hi. Auf.) as occurring about the os externum and on either or l><>th 
the anterior and posterior lips of the cervix. The ulcers are ellip- 
tical in shape with sharply defined vdgv*, shallow or dee]), generally 
with yellow purulent covering. Good-sized fungous granulations 
are apt to be found on the surface. These ulcers are to be differ- 
entiated from cancerous ulcerations by their irregular and sinuous 
borders, their rapid disintegration, and the crater-like excavations 
of their tissues. Syphilitic lesions elsewhere in the body assist in 
making the diagnosis, the microscope being the court of last resort. 

Diagnosis of Adeno-carcinoma of the Cervical Canal 

In this form the diagnosis is of necessity difficult. Palpation 
will show usually thickening of the cervix and perhaps a aodular 
feeling. If the external os is normal, a aodular thickening and the 
detection of a bloody discharge from the os may be all of the 
picious signs. 

If the os is open because of tears, ulcerated and indurated ai 
in the canal may be both palpated by the finger in the canal and 



276 DIAGNOSIS OF MALIGNANT DISEASES OF THE UTERUS 

seen with a uterine or bladder speculum. With the aid of a sharp, 
stiff-shanked curette, tissue is removed for microscopic examination. 

In the infiltrating variety where there is no ulceration, palpation 
having shown localized thickening of the tissues, the external os 
should be dilated under ether and a piece of tissue excised for a 
microscopic examination. 

In curetting the body and fundus of the uterus it is very easy 
to overlook this situation. The physician should bear in mind 
always that the cervical canal is one of the points of origin of 
cancer. 

Differential Diagnosis of Adeno-carcinoma of the Cervical Canal 

This form of cancer of the uterus is to be differentiated from 
interstitial myoma, and chronic cervical endometritis in old women. 

As to the former, the infiltration of the tissues surrounding the 
center of the disease distinguishes carcinoma from myoma. In 
the case of the latter the mucous membrane of a chronic endocervi- 
citis is more normal to sight, although not necessarily so to the 
touch, and the curette carries away little tissue. Tissue is removed 
and the microscope tells the last word. 

Diagnosis of Cancer of the Body of the Uterus 
(Adeno-carcinoma) 

The symptoms are the chief guide to a diagnosis of cancer of 
the body of the uterus. Bleeding alternating with a watery dis- 
charge, occurring in a woman who is past the menopause, and the 
exclusion of fibroids and of cancer of the cervix, make cancer of 
the body probable. Cancer of the body of the uterus is more com- 
mon in nulliparae than in women who have borne children. There 
is sometimes a characteristic odor to the uterine discharge in cancer. 
It can not be described, however. A recurrent pain, similar to 
labor pains, coming on regular days and of several hours' duration, 
the so-called Simpson symptom, has been described as character- 
istic of cancer of the body. This sort of pain is found also in myoma 
of submucous evolution and must be interpreted as the result of 
the stimulation of the uterus by a foreign body which it is trying 
to expel. There is nothing characteristic in the uterine discharge 
of cancer to distinguish it from the discharge from myoma, except 



CAXCER OF THE UTERUS 277 

that on microscopic examination cancer elements may be dis- 
tinguished in it. A uterine discharge occurring in a woman pasl 
forty should lead to an investigation. 

So, also, palpation gives no characteristic feeling. There should 
be slight enlargement of the body; there may be tenderness. In 
patients with very thin or lax abdominal walls it may be possible 
in exceptional cases to make out a localized tumor in the body 
of the uterus. This is unusual. 

The diagnosis is established by exploration of the cavity of the 
uterus, first with the sound and then with the curette forceps or 
the finger. The sound will detect friable tissue, the curette forceps 
will remove it for microscopic examination. Every part of the 
uterine cavity must be reached by the curette, as the initial lesion 
may be very small and easily overlooked. 

The curette forceps are especially valuable in this case, for they 
pinch off and remove tissue without tearing it to pieces. The finger 
introduced to the fundus can recognize beginning cancer of the 
mucous membrane. 

In order to examine with the finger ether must be administered 
and the cervix dilated with steel branched dilators and large I [egar 
dilators. A method devised by II. A. Kelly, consisting of an an- 
terior colpotomy and division of the anterior wall of the cervix 
(see page 94), is of value often in exploring the interior of the 
uterus. As in the other forms of uterine cancer, the microscope is 
the means of a sure diagnosis 

Differential Diagnosis of Cancer of the Body of the I r terus 

The differential diagnosis is a matter of the microscopic exami- 
nation. The physician should remember thai sarcoma of the endo- 
metrium, necrotic myoma, mucous polypi, the products of concep- 
tion, or hydatidiform moles may be found in the uterine cavity. 
The characteristics of cancer of the fundus have been referred bo 
already (page 201)). 

Before leaving the subject of uterine cancel- it isweHtodrav 
tention to the great difficulty often experienced in determining 
whether a thickening in the broad ligaments is of inflammatoi 
of cancerous origin. It is well to bear in mind thai most thicken- 
ings are the result of old pelvic inflammation. Cana ; n 



278 DIAGNOSIS OF MALIGNANT DISEASES OF THE UTERUS 

vene, however, and then it may be assumed that all of the indura- 
tion is due to the cancerous infiltration. The history of the case 
is of some assistance in differentiating the two. 

If there has been pelvic inflammatory disease, it will be shown 
by a history of difficult and infected labors and abortions and a 
history of old attacks of " inflammation of the bowels." We have 
seen what are the usual routes of infection of the surrounding 
tissues in the different forms of uterine cancer, both as to the cellu- 
lar tissue and the glands. Then we know that cancer of the body 
seldom extends to the broad ligaments and to the lymphatic glands 
except in the late stages of long neglected cases, whereas cancer of 
the cervical canal extends to the surrounding tissues relatively 
early. 

THE DIAGNOSIS OF SARCOMA OF THE UTERUS 

Sarcoma of the uterus is of very rare occurrence. It is most 
often found between the ages of forty and sixty. W. A. Edwards 
(Amer. Jour. Med. Sci., July, 1909) has recently collected 16 cases 
of sarcoma of the uterus in children who were fifteen years of age 
or younger. It forms about 4.8 per cent of all malignant growths 
and 2 per cent of all uterine tumors. (E. Hurdon, Kelly and Noble, 
" Gynecology and Abdominal Surgery," Vol. L, p. 151.) It is a 
disease originating from connective-tissue elements as contrasted 
with epithelial elements from which carcinoma arises. There is to 
be noted in sarcoma not only a numerical increase in the number 
of cell elements, a hyperplasia, but also a change in the original 
type, heteroplasia. The small round or spindle cells acquire large 
nuclei, many times larger than the nuclei of the original cells of 
the connective tissue. There is great proliferation of the cells 
into the surrounding tissues and later metastases by the blood- 
vessels to distant organs. The proliferation is not everywhere 
uniform: larger and smaller cells lie together, so that the distin- 
guishing characteristics of sarcoma are the change in the type of 
the cells and the dissimilarity of their arrangement. In sarcoma 
the tumor parenchyma is richly vascularized, carrying its own 
blood supply; whereas in cancer the blood-vessels are contained 
only in fibrous septa. Therefore sarcomata are full of blood and 
are not so apt to be found in a degenerated condition. 



SARCOMA OF THE UTERUS 279 

Three varieties are recognized by pathologists: spindle-celled 
sarcoma; giant-celled sarcoma; and small round-celled sarcoma. 
The last is the most difficult to diagnose microscopically, especially 
if only small pieces are furnished from a curetting. The dis 
may originate in any of the structures of the uterus where con- 
nective tissue is found, in the interglandular connective tissue of 




Fig. 113.— Round-celled Sarcoma of the Body of the Qterufl. Cullen.) 



the endometrium, in the connective tissue of the myometrium, 
or about the blood-vessels. One of the tnosl frequent seat* 
preexisting myoma of submucous or interstitial development; 
the next most frequent is the body of the uterus, and the 
frequent is the cervix. 

In sarcoma of the body of the uterus, if the disease origii al 
the endometrium, there is a diffuse thickening and infiltration of 
the endometrium, accompanied often by more or less defin 



280 DIAGNOSIS OF MALIGNANT DISEASES OF THE UTERUS 

circumscribed outgrowths. The growth is soft and friable, con- 
sisting of a homogeneous brain-like substance very well vascular- 
ized. 

Sarcoma of the muscular wall usually occurs as a circumscribed, 
nodular growth and rarely as a diffuse infiltration. 

Sarcoma of the cervix occurs in two forms, a polypoid tumor of 
soft consistency and smooth surface, attached by a broad base, 
or a tumor made up of many little blebs of tissue of different sizes, 
racemose in character, something like a hydatidiform mole or the 
grape-like vaginal sarcomata of infants. These latter tumors are 
sometimes called myxosarcomata. 

The diagnosis of sarcoma can not be made without the aid of the 
microscope. Metastases by way of the blood current occur in 
about a fourth of the cases of sarcoma of the endometrium, accord- 
ing to G. Winter. They are in the lungs, intestine, and peritoneum. 
The lymph glands are very seldom involved. Metastases from 
sarcomata of the uterine wall or myomata invaded by sarcoma 
are more frequent, being found in the lungs, liver, and intestine. 



THE DIAGNOSIS OF MALIGNANT CHORIOEPITHELIOMA 

Sanger in 1889 (M. Sanger, " Ueber Deciduome, ,} Centralb. f Gyn., 
1889, Bd. 13, p. 132) reported a case of deciduosarcoma: a tumor 
developing in the uterine cavity after pregnancy and followed by 
metastases to distant organs. Soon other observers reported 
similar tumors under the names, Deciduoma malignum, Deciduo- 
sarcoma, Placentoma, Syncytioma malignum, Malignant hydatidi- 
form mole, or other names. 

Marchand (F. Marchand, "Ueber das maligne Chorioepitheliom 
nebst Mittheilung von zwei neuen Fallen/' Zeitschr.f Geb. u. Gyn., 
Bd. 39, p. 173) in 1895 and the following years showed that the 
tumor originates in the epithelial cells covering the chorionic villi, 
and is of a fetal rather than a maternal (decidual) source, hence 
the name Chorioepithelioma, which has since been generally 
adopted by the many authors reporting cases. 

The disease consists of a tumor without sharply defined border 
developing in the mucous membrane of the body of the uterus 
(very rarely in the Fallopian tube or the vagina) and invading the 



MALIGNANT CHORIOEPITHELIOMA 



281 



mucous structure. It is dark rod in color, of soft consistency, 
and abundantly supplied with blood. It has a tendency to 1hmm.hh' 
gangrenous and in that case has a foul odor. 

The surface is apt to be unevenly tabulated. On cross section, 
the structure is seen microscopically to be made up of fibrous 
septa and large spaces filled with extravasated, clotted blood, or 
placental tissue. Larger or smaller nodules an 4 to be seen in the 
uterine muscle, which becomes often very thin when the dis< 
has nearly penetrated to the peritoneum. The metastases show 




Fig. 114. — Chorioepithelioma of the Posterior Wall of the [Items. (Winter.) 



the same characteristics. In the later stages there are numerous 
metastases from the growth, no1 only in the neighborhood of the 
uterus but in distant organs, mosl commonly in the lungs, and the 
disease proves fatal in a majority of cases. 

The disease never occurs excepl after pregnancy, mosl often 
after hydatidiforni mole and abortion. It generally occurs onl) 
a few weeks after the pregnancy, but may be delayed 
months. 

The usual chain of happenings in the case of chorioepithelioma 



282 DIAGNOSIS OF MALIGNANT DISEASES OF THE UTERUS 

is as follows: hemorrhages occurring after abortion or the delivery 
of a hydatidiform mole, curetting and the removal of tissue without 
stopping the bleeding, quickly developing anemia, and signs of 
metastases in the lungs (pain, hemoptysis, and rise of temperature). 
It is plain that prompt hysterectomy is indicated in order to save 
life. In exceptional cases the ovum which has grown a chorioe- 
pithelioma is (a) in the Fallopian tube and not in the uterus, and 
in still rarer cases (b) in the wall of the vagina. 

These cases are called Ectopic malignant chorioepithelioma. In 
the first, (a) the symptoms are those of extra-uterine pregnancy, 
and in the second, (b) they are the same as in the uterine variety. 
The primary disease in the vagina being more accessible to sight 




Fig. 115. — Metastasis in the Vagina from Chorioepithelioma of the Uterus. 

(Winter.) 



and touch, the diagnosis should be made more promptly than 
when it is in the uterus. 

According to J. Veit ("Das maligne Chorioepitheliom," Hand- 
buch d. Gyn., ii. Auf., Bd. 3, 1908) microscopic study of the tissues 
shows that syncytium, Langhans' layer, and connective tissue of 
the chorion, when all present in the same case, are found primarily 
in the veins of a uterus that has been pregnant, and especially after 
hydatidiform mole. If the epithelial cells of the chorionic villus 
proliferate rapidly in the veins, being well nourished, the process 
is malignant. The factor which determines the malignancy of the 
growth is the proliferating power of the epithelial cells and not 
the invasion of the veins by the connective tissue of the chorion. 

If by chance the proliferating epithelial cells of the villus get 



MALIGNANT CHORIOEPITHELIOMA 

into other tissues than the veins, as, for instance, into the peri- 
toneum, the process ceases. A non-malignant form of the disease 
has been reported, and at the present time authorities are not 
agreed as to the reason for the two forms or as to their differ- 
entiation before the specimen reaches the pathological laboratory, 
therefore it is safe to assume that every case of chorioepithelioma 
is malignant and treat it accordingly. 

Diagnosis 

The diagnosis depends on the apparent recurrence of a placental 
polyp after abortion or a hydatidiform mole, with hemorrhage, 
and a watery, foul discharge. Rapidly developing anemia under 
such conditions is a suspicious symptom, as the anemia develop- 
more rapidly in this than in any known disease. Tissue removed 
by the curette or curette forceps is submitted to microscopic exam- 
ination. Better still the cervix is dilated until the canal will admit 
the physician's forefinger and digital exploration demonstrates 
the presence of a soft tumor. 

The tissue of a chorioepithelioma is much more friable and 
softer than that of a placental or other polypus. The uterus is 
found to be somewhat enlarged when the bimanual touch is prac- 
ticed. In most cases it is not sensitive. 

In cases of hydatidiform mole the physician should keep his 
patient under observation for several weeks after the mole has 
been delivered and should bear in mind the possibility of the 
development of a chorioepithelioma. Early removal of a chorioepi- 
thelioma is attended by lasting cure. 



CHAPTER XVII 
THE DIAGNOSIS OF DISEASES OF THE OVARIES 

Anatomy and age changes, p. 284. 

Anomalies, p. 285. Atrophy, p. 285. 

Displacements, p. 286: Undescended ovary, p. 286. Prolapse of the 
ovary, p. 286. Hernia of the ovary, p. 288. 

Inflammations (Ovaritis), p. 288: Acute ovaritis, p. 288; Diagnosis of 
acute overitis, p. 288. Chronic ovaritis, p. 290. Diagnosis of chronic 
ovaritis, p. 290. 

Tumors of the ovary, p. 291 : Modes of development, p. 292. Classifica- 
tion, p. 293. Malignancy, p. 293. Etiology and symptoms, p. 293. Di- 
agnosis in general, p. 295. Diagnosis of small ovarian tumors, p. 296; 
Differential diagnosis of small ovarian tumors, p. 296. Diagnosis of large 
ovarian tumors, p. 301; Differential diagnosis of large ovarian tumors, 
p. 305. Tables, pp. 308, 309. 

Complications of ovarian tumors, p. 315: 1. Adhesions and incarceration, 
p. 315. 2. Intraligamentous development, p. 316. 3. Torsion of the pedicle, 
p. 317. 4. Infection and suppuration, p. 318. 5. Degenerative processes, 
including malignancy, p. 318. 6. Rupture, p. 319. 7. Association with 
pregnancy, p. 320. 

Diagnosis of the different pathological varieties of ovarian tumors, p. 321. 

ANATOMY AND AGE CHANGES 

At birth the ovary is an elongated body, lying parallel with the 
Fallopian tube and resembling in shape a flattened cucumber. 
(See Fig. 117.) Its surface is smooth, its borders may be crenate, 
and it may have a longitudinal furrow. At puberty it has become 
transformed into a smooth olive-shaped gland, grayish-pink in 
color, If inches long (4 cm.), J to 1 inch broad (2 to 2.5 cm.), and 
J inch thick (1 to 1.5 cm.) and weighing about 2 drams (6 grams). 

From puberty to the menopause it maintains the same size and 
shape, but the smoothness of its surface is marred by scars, the 
results of repeated lacerations caused by the rupture of the ripe 
Graafian follicles. (See Fig. 118.) 

After the menopause the ovary shrinks and becomes wrinkled 
and atrophic, and at the age of seventy weighs about one gram. 
(See Fig. 119.) 

284 



ANOMALIES 






ANOMALIES 



Congenital absence of both ovaries is rare and is associated with 
defective development of the uterus and partial or complete ab- 
sence of the vagina. Absence of one ovary usually accompanies 
deficiency of the corresponding half of the uterus and the Fallopian 
tube, and absence or misplacement of the kidney on the same side 
of the body. There is on record no reliable description of a super- 
numerary ovary: the bodies described as such being corpora fibrosa, 
small myomata of the ovarian ligament, or partially detached tubes 




uterus 



Fimbria ucarica. 

Fig. 116.— The Ovary and Tube Seen from Behind. Henle.) 



of the parovarium. Faulty growth of the ovary is commonly 
associated with the uterine condition known as infantile uterus, 
also with rudimentary uterus. 

Atrophy of the ovaries occurs normally at the menopause. They 
become smaller and harder and the oophoron (the egg-bearing 
zone on the outside of the ovary) is transformed into a layer of 
dense fibrous tissue. Lactation (itr<>/>lii/ is a shrinkage in tin 
of the ovary occurring Bometimes in women who have nursed their 
children for a long time. Ovarian atrophy has been reported m 
the exanthemata, myxedema, marked anemia, and in diab 
It is supposed to occur in connection with rapidly acquired «''»« 



286 DIAGNOSIS OF DISEASES OF THE OVARIES 

At all events young women who have suddenly become fat fre- 
quently suffer with amenorrhea. On account of the increase in 
fat in the abdominal walls it is not easy to determine a decrease in 
the size of the ovaries in these patients, but in certain cases atrophy 
has been definitely made out. 

In 1900 I opened the abdomen in a case of absolute amenorrhea 
of eight months' duration following steaming of the uterine cavity 
at the hands of another practitioner. The woman was twenty- 
eight years old, the mother of two children. The ovaries were 
found to be partially atrophied as well as the uterus. 

DISPLACEMENTS OF THE OVARY 

(a) Undescended ovary, (b) Prolapse of the ovary, (c) Hernia of 
the ovary. 

(a) Undescended Ovary. — The ovaries are in close relation with 
the kidneys in the embryo and they gradually move downward 









-—^ 






Tube 




>■-:". 




. 




.,'-■ " ■ --. ' 






^ft; 






21 


^QuT 


f-r't ng<;s 






Ov ary^ 
_ Cervix 


w 



Fig. 117.— Uterus, Tubes, and Ovaries of an Infant One Month Old. 

to the pelvis, at birth lying on the psoas magnus muscle in close 
relation with the internal abdominal ring. They get to their 
normal situation in the adult soon after birth. It may happen in 
very rare instances that an ovary may remain in the neighborhood 
of the kidney and may retain its infantile shape. If it is the right 
ovary that has failed to descend the cecum also generally remains 
high up, in its fetal position. 

(b) Prolapse of the ovary may occur when from repeated preg- 



DISPLACEMENTS OF THE OVARY 



287 



nancies the ovarian and broad ligaments have been stretched and 
subsequently not properly involuted, permitting the ovary to sag 
back into Douglas' cul-de-sac. Also when an ovary is enlarged 
for any reason and thus gravitates of its own weight to the pelvic 
floor. Misplacements of the uterus, such as retroversion and 
retroflexion, are commonly associated with prolapse of the ovaries. 
Prolapsed ovaries may be tender to touch, when we may assume 
that they are the seat of inflammation, ovaritis. In this event 



Utero - o v arian 
I i g anient 



Tube 




Broa d tig- es.me\-\t 






Fig. 118.— Ovary and Tube of a Woman during Sexual Maturity 

they may cause suffering when pressed on during the ac1 ol del 
tion, especially the left ovary, or during coitus. The diagno 
established by the bimanual tough. Absence of the ovary in its 
normal situation and its presence a1 the base of the broad ligament 
as determined by rectal touch are tin- diagnostic points. It is 
often difficult to differentiate a prolapsed ovary from a small 
scybalous mass in the rectum. In order to do this successfully, 



288 DIAGNOSIS OF DISEASES OF THE OVARIES 

thoroughly cleanse the rectum by enema, and examine a second 
time. In some cases it is well to use the proctoscope to be sure 
that the upper rectum is free. If the ovary is tender distinguish- 
ing it is easier. 

(c) Hernia of the ovary is comparatively rare in adults but occurs 
not infrequently in infants under a year and a half old. It may 
occupy a hernial sac either alone or accompanied by its Fallopian 
tube. Ovarian hernia is more apt to occur as an inguinal than 
as a femoral hernia. Congenital hernia of the ovary is very 
rare, but it may occur in the early months of infancy because 
the ovaries and tubes at this time normally lie in close prox- 
imity to the abdominal ends of the inguinal canals. (See Fig. 
206.) Many cases reported as hernia of the ovary are hydroceles 
of the canal of Nuck. Hernia of the ovary may occur at any 
age up to the seventy-third year. The diagnosis can be made 
definitely only by operation. It is difficult to be sure of the 
absence of the ovary on one side. A hernia — preferably an 
inguinal hernia — having a tender body in it, while at the same 
time the ovary on that side can not be palpated in its normal 
situation, makes a probable diagnosis. 



INFLAMMATIONS OF THE OVARY 

Ovaritis may be acute or chronic. The acute form occurs in 
infections following labor or abortion, gonorrhea, typhoid fever, 
miliary tuberculosis, the acute exanthemata, or mumps. The 
ovary is enlarged and congested, the oophoron or the paroophoron 
being involved, or both. The tissues are infiltrated with serum, 
leucocytes which have escaped from the blood-vessels, and some- 
times with blood. If there is a large collection of blood, a hema- 
toma of the ovary is formed. Abscess of the ovary may be the result 
of severe grades of inflammation and a tumor which reaches the 
size of an egg may eventuate. There are apt to be adhesions to 
the surrounding structures, such as the Fallopian tubes and in- 
testines. The abscess may rupture into the intestine, bladder, or 
vagina. It has been known in rare cases to break into the general 
peritoneal cavity, causing fatal peritonitis. 

Diagnosis of Acute Ovaritis.— Pelvic pain aggravated by move- 



INFLAMMATIONS OF THE OVARY 






merit of the body or by defecation, and tenderness on pressure in 
the ovarian regions, are characteristic of a mild attack of ovaritis. 
Chills and marked elevation of the body temperature are to be 
expected if suppuration occurs. If there is peritonitis of any 
extent there will be rigidity of the abdomen and a rapid and small 
pulse and increased pain. If it is possible to palpate the ovary 
it will be found enlarged and exquisitely tender. Commonly the 
rigidity of the abdominal walls prevents exact differentiation of 
the structures involved. An abscess is usually fixed in a ma— of 
exudate. Fluctuation may be made out by rectal palpation, but 





- 




Utc rus 


Tu.be J J^ 




J'^SA 




Atrophied / ^^^S^B^^ 




ovary \ , JttM *g?''"^ 








I _JrW'^F 40* 




'•■ \ .-~jT jta 






\^>y »"»< 


1 ied-^ervt 


~* a ^Bt*?*' 




BP^ 



Fig. 119.— Senile Ovary and Tube. 

often the wall of the abscess is so thick thai this is impossible. 
In the case of acute ovaritis il is impossible to distinguish exactly 
between ovaritis and salpingitis. If the disease is right-sided we 
must, if possible, eliminate appendicitis. The history of the onsel 
is the important point in distinguishing the two. Acute pelvic 
inflammation is generally preceded by a vaginal discharge or other 
uterine symptoms such as dysmenorrhea, whereas in appendicitu 
there is a history of digestive disturbances, such as diarrhea alter- 
nating with constipation, or of previous attacks of pain m ' 
right lower abdomen. The pain of pelvic disease is dull and - 
and is situated deep in the pelvis, pressure over Poupart'a ligament 

19 



290 



DIAGNOSIS OF DISEASES OF THE OVARIES 



occasioning great suffering. The pain of appendicitis is sharp 
and colicky and is higher in the abdomen and is more diffused. 

If the appendix happens to be in the pelvis or if there is much 
peritonitis it is impossible to distinguish the two affections. 

Chronic ovaritis may follow an acute ovaritis or it may originate 
in an infection of the uterus, especially in gonorrhea. It is also 
found in the presence of fibromyomata and large ovarian tumors 
of the opposite side, although the disease is generally bilateral. 

The oophoron is usually affected, the Graafian follicles often be- 
coming enlarged and causing atrophy of the stroma because of their 
size. Such a condition is called small cystic degeneration. In certain 
cases the entire cortical region of the ovary (oophoron) is trans- 
formed into little cysts containing a clear fluid, the ovum having dis- 




Fig. 120. — Diagram Showing the Cyst and Tumor Regions of the Ovary. 

(After Bland-Sutton.) 

appeared. Now and then a few normal follicles may be found. In 
some cases of chronic ovaritis, the stroma and not the follicles is in- 
volved. In the late stages of this disease the ovary is found small and 
scirrhotic with a puckered, uneven surface, as from many scars. 

Diagnosis of Chronic Ovaritis. — There is nothing pathognomonic 
in the symptoms of this disease. There is apt to be pain in the 
ovarian regions, and scanty menstruation if the ovarian stroma 
has been destroyed, also dysmenorrhea. The ovaries may be 
tender to the touch; often they are not. The bimanual touch may 
determine follicular enlargement or a nodular feel. In only ex- 
ceptional cases when all the factors are favorable, more especially 
at an examination under an anesthetic, can a small cirrhotic ovary 
be diagnosed. 



OVARIAN TUMORS 291 



OVARIAN TUMORS 



We have considered already certain states of the ovary that 
strictly may be classed as tumors, for instance, "small cystic de- 
generation" and inflammatory conditions with enlargement. 

Let us now take up ovarian tumors proper, counting as tumors 
all enlargements of the ovary greater in size than a hen's egg, using 
Pfannenstiel's classification based on the origin of the tumor. 
(Veit's "Hanclbuch," J. Pfannenstiel, "Die Erkrankungen des 
Ovarium.") 

A. Nox-Proliferatixg Cysts. 

(Follicular cysts; Cysts of the corpus luteum.) 

B. New Formations. 

I. Parenchymatogenoiis Tumors. 

(Tumors arising from germinal or follicular epithelium 
or from the ovum.) 

1. Epithelial New Formations. 

(a) Cystoma serosum simplex. 

(Simple cyst.) 

r Pseudomucinosum. 

I (Multilocular cysts. 

(b) Cystadenoma ; a 

w J Serosum. 

[ (Papillary c\ 

(c) Carcinoma. 

2. Embryomata. 

(Tumors springing from the ovum.) 

(a) Dermoid cysts. 

(b) Teratomata. 

II. Stromatofjcjious Tumors. 

(Tumors arising from the connective tissue.) 

1. Fibroma. 

2. Sarcoma. 

3. Peri- and Endothelioma. 

C. Mixed Tumors. 

(Various combinations of the tumor processes enumerato d. 

Fig. 120 shows diagrammatically the differenl portion 
ovary affected by neoplasms. 



292 



DIAGNOSIS OF DISEASES OF THE OVARIES 



Modes of Development of Ovarian Tumors 

The accompanying diagrams indicate the method of develop- 
ment of the pedicle of a tumor and the arrangement of the peri- 
toneum in the case of the normal ovary, a free ovarian cyst, an 
intraligamentous cyst, and an adherent ovarian cyst. It is plain 
that the broad ligament, the Fallopian tube, the round ligament, 



TMicle. 



fallopian 
'■ tube 



V?f\7v.lhpiaqtube 
vyesosalpiqy- 

Q))tfouncl 

7/gameqt- 




Figs. 121-124. — Four Diagrams Showing the Method of Formation of the 
Pedicle in the Different Sorts of Ovarian Tumors. 

and the ovarian ligament are included in varying degrees in the 
pedicle of a large non-adherent ovarian tumor. Commonly the 
Fallopian tube is much elongated and spread over the surface of 
the tumor, the round ligament comes on to the anterior face of the 
tumor, and the ovarian ligament is much enlarged and lengthened. 
In the case of tumors developing between the layers of the broad 
ligament, or of adherent ovarian tumors, the conditions are as 
shown in the diagram. A parovarian cyst may lie free in the 



OVARIAN TUMORS 

pelvis attached only by a pedicle formed from the broad ligament, 

and it is not unusual to find such a cyst as a complication of a small 
ovarian tumor. 



Classification 

Ovarian tumors have been generally classified as solid or cystic, 
and benign or malignant. As will be seen from the classification 
of Pfannenstiel, such a division is arbitrary and many of the tumors 
are both solid and cystic, and also benign and malignant. This is 
shown by careful microscopic examination in the pathological 
laboratory where a unilocular cyst will be found often to have 
small cysts in its walls, or trabecular in the cyst walls, denoting 
former subdivisions. Some of the multilocular cysts show papillary 
masses in certain regions, while in other places small dermoid cysts 
may be discovered, and even areas of cancerous degeneration. 



Malignancy 

A benign tumor is one which does not tend to recur when extir- 
pated, as well as one which does not implant itself elsewhere or 
invade the tissues. 

A malignant tumor signifies a growth which tends to destroy life 
by invasion of the surrounding tissues as well as one which dis- 
tributes its elements by metastasis to other part- of the body. 

In a general way one may say that the cystadenomata (multi- 
locular cysts), the parovarian cysts, the fibroids of the ovary, and 
the dermoid cysts are benign; the carcinomata and sarcomata are 
malignant, and the papillary tumors are od the border land. That 
is to say, the papillary cystadenomata tend to implant their ele- 
ments on the surrounding structures, there to grow, but they do 
not invade the underlying structures as do the carcinomata and 
sarcomata. 

Etiolocy WD Symptoms 

Ovarian tumors are found most often during the time of Bexual 
activity in the life of women, but may occur at any age. Chiene 



294 



DIAGNOSIS OF DISEASES OF THE OVARIES 



and F. B. Lund have each removed an ovarian cyst from a child 
three months old, and Thornton operated successfully on a woman 
ninety-four years of age. 

It is supposed that the germ of most tumors exists from fetal 
life and that when the proper stimulant comes the tumor develops. 




Fig. 125. — Very Large Ovarian Cyst with Characteristic Emaciation about 
the Chest and "Facies Ovarina." (Kelly.) 



The controlling factors are unknown. The symptoms consist, 
during the early stages of the growth of an ovarian tumor, in the 
usual syndromata of uterine disease, and may be of little moment 
to the patient, so that her attention is not directed to the pelvis. 
They are menstrual disturbances, — such as dysmenorrhea, menor- 






OVARIAN TUMORS 295 

rhagia, or scanty menstruation,— a sense of weight in the pelvis, or, 
if there is peritonitis, pain. When the tumor attains a considerable 
size, so that it fills the pelvis or rises out of it into the abdomen, 
there are pressure symptoms. These are vesical or rectal tenes- 
mus, frequent micturition, and constipation; in the case of large 
tumors, edema of the vulva and of the lower extremities caused 
by pressure on the iliac veins; also hemorrhoids. In rare i 
there have been noted albuminuria and suppression of urine from 
hydronephrosis caused by pressure on the ureters. Other symp- 
toms are jaundice from occlusion of the bile ducts, ascites from 
pressure obstruction to the portal system, dilated veins in the 
skin of the abdomen, the occurrence of the white lines in the .-kin 
known as linese albicantes, occasional umbilical hernia, and de- 
rangements of digestion and dyspnea. 

Pain in the abdomen is a symptom of adhesions, as a rule, and great- 
care should be observed in taking the anamnesis to get the exact sit- 
uation, character, and duration of the pain. Pain is caused also by 
traction or torsion of the pedicle and by secondary changes in the 
contents of the cyst involving adhesions to the sensitive parietal 
peritoneum. 

The fades ovaiina is a peculiar facial expression that i- pathog- 
nomonic of the late stage of large ovarian tumors. It consists 
of an anxious, careworn look; the face is pale and shriveled, there 
being wrinkles in the cheeks, and it looks longer; the nostrils are 
wide and the lips thin, the space between the eyelids and the bony 
margin of the orbits is sunken. The face does not have thai 
yellowish hue characteristic of the late stages of cancel-, nor yel 
the full appearance of the face of the pregnant woman. 

There is also to be noted in large ovarian tumors a loss of flesh 
over the chest and shoulders, probably of a piece with the atrophy 
of the face just described. 



Diagnosis in Geneb \l 

In considering the diagnosis of ovarian tumors it is convenienl 

to divide them into small tumors, those that lie wholly within the 
pelvic cavity proper, and large tumors, those that li<- i"i the 
part in the abdominal cavity. We will discuss the d and 



296 DIAGNOSIS OF DISEASES OF THE OVARIES 

the differential diagnosis of each, then take up the complications 
of ovarian tumors, and finally say something of the diagnosis of 
the different pathological varieties of tumors, as far as they can be 
distinguished without operation. 

The important factor in the diagnosis of all ovarian tumors 
is to determine the relation of the tumor to the uterus. 

If it can be shown that moving the tumor moves the uterus, or, 
conversely, that changing the position of the uterus moves the 
tumor, there is a probability that the tumor is ovarian. On ac- 
count of adhesions and intraligamentous development, all ovarian 
tumors are not movable. The tumors of medium size, those that 
have risen out of the pelvis but have not yet distended the ab- 
dominal walls to excessive degree, are easiest to palpate with 
reference to their connection with the uterus. To perform the 
palpation to the best advantage, use is made of the bimanual 
vagino-abdominal touch. 

With the forefinger against the cervix, push the tumor in the abdo- 
men or pelvis to one side with a quick movement of the hand on the 
abdomen. At the same moment the cervix will be felt to move be- 
cause of the pull on the pedicle of the tumor. Sometimes, but not 
often, a quick push on the uterus by the finger in the vagina will be 
transmitted to the tumor, as detected by the hand on the abdomen. 

To palpate the pedicle the cervix is grasped by a double tenacu- 
lum held by an assistant while the physician practices the bimanual 
recto- abdominal touch, with two fingers in the rectum. (See Fig. 
126, page 301.) 

In this way it is possible sometimes to get a good idea of the 
situation, size, and length of the pedicle of a tumor. As pointed 
out by John A. Sampson (" Surgery, Gynecology and Obstetrics," 
1907, Vol. IV., p. 685), traction on the pedicle of an ovarian tumor 
causes pain. Also twisting of the pedicle, as determined by opera- 
tions performed on patients by the aid of local anesthesia, causes 
pain which is referred to the pelvis on the side on which the pedicle 
is situated. 

Diagnosis of Small Ovarian Tumors 

Those tumors, which lie entirely within the cavity of the true 
pelvis, are diagnosed by the bimanual touch, both vagino-abdominal 



SMALL OVARIAN TUMORS 

and recto-abdominal. In the case of the small tumor it is difficult 
to make out the characteristics of the pedicle. One determines 
this in some cases as described above. We try to ascertain the 
position, size, form, and density of any given pelvic tumor; then 
its relation to the uterus. If the tumor is small there is a likelih< >< x 1 
that the uterus can be placed and its size and shape defined by 
touch. In the larger tumors, those filling the pelvis, such palpa- 
tion is difficult or impossible. In this event the sound must be 
passed to determine the location and relative size of the uterus. 
As a rule, ovarian tumors are round. This is always the case with 
the cysts, the solid tumors being generally, but not invariably, 
round. A fluctuating consistency can be made out in most a 
of cysts. A small-sized ovarian cyst is to be looked for in the 
situation of the ovary, and is movable (rarely adherent) ; an int ra- 
ligamentous cyst lies to one side and behind the uterus, and is 
immovable. A cyst may lie in front of the uterus, rarely, and, of 
course, there may be two ovarian tumors, one on each side. 

Differential Diagnosis of Small Ovarian Tumors 

We must rule out. : 

1. Ovaritis. 

2. Subperitoneal fibroid. 

3. Parovarian cyst. 

4. Hydrosalpinx, hematosalpinx, and pyosalpinx. 

5. Encapsulated peritonitis, or inflammatory exudate. 

6. Echinococcus cyst. 

7. Extra-uterine pregnancy. 

8. Early normal pregnancy, or cornual pregnancy. 

9. Distended urinary bladder. 

i. Ovaritis. — Tumors of the chronic form of ovaritis are seldom 
larger than a pigeon's egg, but the acute form resulting in abe 
may be of considerable size Here there is fever, and the tumor is 
of recent occurrence, an acute affair. The tumor is ten. Id-, and 
there is pelvic peritonitis in varying degress of intensity as evi- 
denced by rigidity of the abdominal walls. Also there is generally 
a history of infection. 

2. Subperitoneal Fibroid.— The differentiation in this ften 



298 DIAGNOSIS OF DISEASES OF THE OVARIES 

a difficult matter and depends entirely on the findings from palpa- 
tion. The consistency of an ovarian cyst is softer than that of a 
subserous fibroid. As a rule, the fibroid is more intimately allied 
with the uterus, and in many cases the pedicle is short and thick 
or the growth is sessile. It helps in the diagnosis if other fibroid 
nodules can be distinguished in the substance of the uterus, for 
fibroids are apt to be multiple. The coexistence of ovarian cyst 
and fibroid is not an uncommon occurrence. 

In the case of an interstitial fibroid the uterus should be enlarged 
and menorrhagia is apt to be a symptom; the passage of the sound 
will show an increased depth of the uterine cavity. 

If, by any chance, both normal-sized ovaries can be palpated, the 
tumor is a uterine fibroid. 

3. Parovarian Cyst. — Parovarian cysts are generally relatively 
small in size, therefore they are put here. They may be large, 
however. The cyst arises from the epoophoron, is generally uni- 
locular, and has a thin wall, with clear serous contents. It is situ- 
ated between the tube and ovary and is intra-ligamentous in growth; 
therefore, when the cyst has developed the tube is on its upper 
surface and the ovary below it. In extremely rare cases the ovary 
may be palpated by the finger in the vagina on the under surface 
of the cyst. As a rule, the differential diagnosis can not be 
made. 

4. Hydrosalpinx, Hematosalpinx, and Pyosalpinx. — The accumu- 
lation of serous fluid, blood, or pus in the Fallopian tube gives it a 
more or less characteristic shape. This is a strong diagnostic 
point. A pyriform swelling with its small end at the uterine horn 
is indicative of a dilated tube. In the case of hydrosalpinx and 
hematosalpinx there is, as a rule, no complicating peritonitis, 
therefore the diagnosis is easier than in the case of pyosalpinx, 
which is apt to be surrounded by exudate. Hydrosalpinx and 
hematosalpinx never reach the great size of exceptional cases of 
pyosalpinx. It is unusual for any variety to be more than an inch 
and a half (3 cm.) in diameter or five inches (12 cm.) long. The 
hydrosalpinx has a thin wall, and fluctuation can be determined 
without much difficulty; pyosalpinx has thick walls because of 
inflammatory action in the tube and also in the peritoneum sur- 
rounding it, and it is not easy to make out fluctuation. 

5. Encapsulated Peritonitis. — If a quantity of serous or purulent 



SMALL OVARIAN TUMORS 

exudate in the case of pelvic peritonitis, or a quantity of ascitic 

fluid becomes encapsulated by peritoneal adhesions, the condition 
may be mistaken for a cystic tumor of the ovary. Such a condi- 
tion is relatively rare, however. Generally there is evidence of 
tuberculosis or carcinosis or actinomycosis of the peritoneum and 
the manifestations of the disease in the general cavity of the peri- 
toneum overshadow those in the pelvic cavity. Such ciicu in- 
scribed collections of fluid in the pelvic cavity have an irregular 
shape and are not often round. Also fluid is apt to be present in 
other portions of the peritoneum. 

6. Echinococcus Cyst. — Echinococcus cyst of the pelvis is rare. 
Primary echinococcus disease of the ovary is unknown, but it 
occurs in the following situations in the pelvis: (a) the uterus, 
(b) the mesometrium, (c) the pelvic bones, (d) the omentum, an.! 
(e) the Fallopian tubes. Also downward extension of hydatid 
disease of the liver may reach the pelvis. Echinococcus cysl is 
round and fluctuates; but, as a rule, is more distended and has 
thicker walls than an ovarian tumor, and it is generally densely 
adherent to the surrounding structures. Bland-Sutton ("Surgical 
Diseases of the Ovaries and Fallopian Tubes."' L891, p. 183 says 
that a " peculiar sign — hyatid fremitus — can sometimes be obtained 
by placing the palm of the left hand upon the tumor and sharply 
percussing with the finger of the right. It is a peculiar tremor or 
thrill, only felt over a hyatid cyst."' In thiscountry hydatid dis- 
ease is very rare. 

7. Extra-Uterine Pregnancy. — This gives a history of pregnancy. 
Before rupture there is a boggy fluctuating or elastic tumor at the 
side and back of the uterus. It is the shape of a distended tube. 
Look for purple discoloration of the vagina with increased dis- 
charge, and for changes in the breasts together with uterine en- 
largement and softening of the cervix, also pain <>n moving the 
cervix. About the time of intra-abdominal rupture of the p 
nant sac the endometrium casts off a modified decidua of pregnane) 
with more or less uterine hemorrhage. At the time of rupture the 
symptoms are 1 hose of hit ra-abdominal hemorrhage and an 
There is a fulness in the cul-de-sac with abdominal distention, 

rapid, feeble pulse, severe pain in the abdomen, and collapse. It 
in a chronic case a hematocele has formed, there U a bo 
in the cul-de-sac, generally filling the pelvis, the uterus beii 



300 DIAGNOSIS OF DISEASES OF THE OVARIES 

front. There may be a history of repeated attacks of pain recurring 
at irregular periods. 

8. Normal Pregnancy. — Early normal pregnancy, particularly if 
the pregnancy begins in one horn of the uterus, may be mistaken 
for ovarian cyst. It should not be forgotten that the two condi- 
tions frequently coexist. First, the history indicates pregnancy. 
Inquire for amenorrhea and morning nausea and whether there 
has been coitus. The uterus in pregnancy is anteflexed, there is 
bulging of the lower uterine segment anteriorly, the uterine tissues 
have a peculiar elastic feel and are compressible by bimanual 
touch (Hegar's sign; see Fig. 178). The cervix is soft and there 
are increased vaginal discharge and purplish discoloration of the 
anterior vaginal wall and introitus vaginae, noticeable as early as 
the sixth week in some instances, though usually not quite so early. 
The breasts are full, the veins showing in the skin; the areolae are 
pigmented and show enlargement of the follicles. There may be 
secretion from the breasts. In the case of pregnancy in one horn 
of a bifurcated uterus the history of pregnancy is to be obtained. 
There is no bulging of the lower uterine segment, but the other 
signs of pregnancy are the same. There is no fluctuation in the 
pregnant uterus until the stage of "ballottement." This is not 
available as a diagnostic sign until the twenty-first week of preg- 
nancy when there is sufficient fluid in the amnion and the fetus is 
heavy enough to give the characteristic feeling as the fetus bobs 
about when jostled by the sudden impact of the examiner's finger 
in the vagina. 

9. A Distended Urinary Bladder. — If the rules for the preparation 
of the patient for an examination have been observed (see Chapter 
IV., page 23) it will have been learned that the patient has been 
unable to urinate, and therefore a catheter has been passed. It 
sometimes happens that a patient is unable to speak the language 
or is unconscious, and the question of ovarian tumor arises. It 
is safe to pass the catheter if there is the slightest doubt that the 
bladder is empty. Upon palpation the full bladder is not so mov- 
able as an ovarian cyst, as a rule, and the uterus is retroverted 
under the bladder. Dribbling of urine is apt to be a symptom of 
an overfilled bladder. 



LARGE OVARIAN TUMORS 



301 



Diagnosis of Large Ovariax Tumors 

Large ovarian tumors are those which are too large to be con- 
tained in the true pelvis and are of abdominal development. They 
fill the abdomen to a greater or less degree and lie on the false 
pelvis. The diagnosis depends in great measure on the determina- 




Fig. 126.— Hegar's Method of Determining the Relation ofTumors to the [Jterra 



tion of the connection of the tumor by pedicle with one or the 
other side of the fundus uteri. If the tumor is very large such 
determination is difficult of accomplishment. If the tumor Is 
smaller, so that there is space to mow it within the abdominal 
walls, moving the tumor will be felt by the finger in the vagina <<> 
pull the uterus at the same time. By rectal palpation, after trac- 
tion on the cervix has been made by a double tenaculum, the pi 



302 



DIAGNOSIS OF DISEASES OF THE OVARIES 



cian may be able to distinguish the situation and characteristics 
of the pedicle. (See Fig. 126, page 301.) 

Inspection. — Inspection of the abdomen of a woman having a 
moderately large ovarian tumor will show the enlargement most 
pronounced on the side from which the tumor has sprung. This 
is not the case with very large tumors. As a rule the enlargement 
is in the lower portion of the abdomen. B. C. Hirst (" Diseases of 
Women," Second Edition, p. 539) has seen three cases in which 
an ovarian tumor was in the upper abdomen — twice due to tight 
lacing and once to the fact that the tumor was elevated in preg- 



Dull 



Tympanitic 




Tympanitic 



Fig. 127. — Diagram of a Cross Section of the Body in the Case of an Ovarian 

Tumor. 



nancy, became adherent to the liver, and did not descend with 
involution of the uterus. 

When the tumor has been long existent we expect to find the 
fades ovarina and loss of flesh about the chest and shoulders. 
Unless ascites is present or the tumor is excessively large, there is 
no bulging in the flanks. 

Palpation. — Palpation usually shows a fluctuating tumor, more 
distinctly felt on the affected side. The elasticity will depend on 
the sort of tumor present, and on the tenseness of the cyst. If 
the tumor is very tense it may feel like a solid mass. It is rare 
for solid tissues to predominate in ovarian tumors. Nodules may 
be felt and loculi of a multilocular tumor if the abdominal walls 
are thin. If the walls are very tense or thick it is necessary often to 



LARGE OVARIAN TUMORS 



303 



administer an anesthetic before a satisfactory examination can 
be made. The mobility of the tumor depends on the length of its 
pedicle, the relation between the size of the tumor and the size of 
its abdomen, and the presence of adhesions. 

By means of the bimanual vagino-abdominal or recto-abdominal 
touch it may be possible to determine that the uterus is not en- 
larged and is separate from the tumor, and the pedicle may In- 
mapped out by traction on the uterus. Also the connection of the 
tumor may be made plain by moving the tumor suddenly, the ini- 




Fig. 128. — Large Parovarian Cyst Seen in Profile. (Kelly.) 

pulse transmitted to the uterus being appreciated by the finger in 
the vagina or rectum. 

Percussion. — With the patient in the dorsal position the tumor 
occupies the lower anterior portion of the abdomen. The intefi 
tines, held by their mesentery, are Dearer tin- diaphragm and 
at the sides of the tumor; therefore tympanitic resonance is found 
in the epigastrium, flatness over the tumor, and dullness or modi 
del resonance in the flanks. These areas of resonance, flatness, and 
dullness do not change with change in the position of the patient, 
as regards the side position or the standing position. If the tumor 
contains fluid, a percussion wave may be elicited by placing a hand 
on each side of the abdomen and then tapping with the finger of 



304 



DIAGNOSIS OF DISEASES OF THE OVARIES 



one hand. A vibration will be felt by the opposite hand. If 
the abdominal walls are very fat the fat may transmit a wave by 
itself; therefore, to eliminate this fat wave have an assistant place 
a hand with the ulnar edge down along the middle line of the ab- 




Fig. 129. — The Various Abdominal Organs from Which Tumors May Arise. 

(Kelly.) 



domen and press firmly. If the fluid in the cyst is thick, as in 
dermoids, the percussion wave may be slight or absent. 

Measurements. — Measurements of the abdomen show an increase 
or decrease in the size of a tumor from time to time. They are 



LARGE OVARIAN TUMORS 305 

made with a tape measure at some definite point, as about the 
body at the umbilicus, or at the anterior superior spines of the ilia. 
Other measurements are, the distance from the tip of the ensi- 
form cartilage to the upper margin of the symphysis pubis and 
a measurement made with the pelvimeter, the patient being in a 
standing position, from the upper apex of MichaehV rhomboid area 
on the back over the sacrum, to the most prominent point of the 
tumor. These measurements must be taken each time with the 
patient in exactly the same position, whether standing or on 
the side and always with the bowels free. 

Aspiration or tapping an ovarian tumor is never justifiable as a 
means of diagnosis, and exploratory incision is to be practiced only 
when it is impossible to make a diagnosis and all the preparations 
have been made for a complete operation. 



Differential Diagnosis of Large Ovarian Tumors 

We must rule out: 

1. Pregnancy. ■ 

2. Ascites. 

3. Fibroids. 

4. Accumulations of gas or fecal matter in the intestines. 

5. Fat or tumors in the abdominal walls, including "Phantom 

Tumor." 

6. Cyst of the pancreas. 

7. Tumors of the spleen, liver, and kidneys. 

8. Cyst of the omentum. 

9. Echinococcus cysts. 

10. Dilated stomach. 

11. Distended urinary bladder. 

i. Pregnancy. — It should be assumed, until the contrary has 
been proven, that every abdominal enlargement in a woman is 
due to pregnancy. In this way many embarrassing mistakes will 
be avoided. The diagnosis of early pregnancy lias been considered 
in treating of the small ovarian tumors. Advanced pregnancy is 
to be excluded by the history. It is possible to have amenorrhea 
in ovarian tumor, especially where both ovaries have become dis- 

20 



306 



DIAGNOSIS OF DISEASES OF THE OVARIES 



organized by the disease affecting them, but it is unusual. Morn- 
ing nausea and vomiting during the early months, or salivation 
and heartburn and swelling of the breasts, are characteristic of preg- 
nancy. Sometimes these symptoms have occurred at a given 
time with previous pregnancies. Ask whether they have been 
observed this time since the patient first noticed the enlargement 
of the abdomen. 

Quickening is usually noticed at the end of the sixteenth week 
of pregnancy. The signs of pregnancy in the later months are 




Fig. 130. — The Height of the Fundus Uteri at the Various Weeks of Pregnancy 

(After Zweifel.) 

softening of the cervix, increased vaginal discharge, ballottement 
after the twenty-first week. Fluctuation in the uterus is. very 
indistinct unless the liquor amnii is in excess and the uterine walls 
are thin from any cause. By careful palpation the intermittent 
rhythmical contractions of the pregnant uterus may be felt as 
early as the fourth month. A good deal of patience, gentleness, 
and skill are necessary to get this sign. Purplish discoloration 



LARGE OVARIAN TUMORS 



307 



of the vulva and anterior wall of the vagina are to be made out from 
the sixth to the twelfth week. If milk or colostrum can be s< raeezei I 
from the breasts it is an important indication of pregnancy. 

Fetal heart sounds can be heard after the twentieth week, and 
fetal movements can be felt after the sixteenth week unless the 
fetus is dead. The tumor has developed relatively rapidly; there 
is pigmentation of the areola? of the nipples, and of the linea alba 
in some cases; edema of the ankles is not uncommon after the 



\ r ^>y<. 




9 WL >t^- 



A 



Fig. 131.— The Abdomen of Ascites Seen in Profile. (Kelly.) 



seventh month; the face shows sometimes the fades utcrina, a 
fullness about the eyes and front of the cheeks. 

In the case of an ovarian tumor there is no softening of the 
cervix; the tumor is distinct from the uterus and is of gradual 
development; there is no ballottemenl and there are no fetal heart 
sounds or movements; also there is absence of pigmentation of the 
areolae and the linea alba: edema of the ankles is rare, except after 
a tumor has existed several years; the superficial veins of the 
abdomen are enlarged, and the facies ovarina is present in the 
case of long-existing tumors. 

Hydramnios, an excess of amniotic fluid, has led many a 
to diagnose ovarian cyst. A careful study of the hi ymp- 

toms and signs of pregnancy and ovarian tumor ought to I 



308 



DIAGNOSIS OF DISEASES OF THE OVARIES 



differentiation relatively easy and sure. In ovarian cyst the 
tumor is of less rapid development, there is no ballottement, and 
the tumor is more on one side than the other, and, most important, 
it is distinct from the uterus. 

2. Ascites. — An accumulation of fluid in the peritoneal cavity 
may accompany an ovarian tumor, and in such a case the diagnosis 
is difficult, and may be settled exactly only at the operation under- 
taken for the removal of the tumor. 

The following table, taken from Dudley's " Gynecology/' with 
modifications, gives the points which serve usually to distinguish 
ascites from ovarian cyst. 



Ascites. 



Large Ovarian Cyst 



1. Previous history of disease of 
kidneys, heart, or liver, or peritoneum. 

2. Enlargement comparatively sud- 
den. 

3. Face puffy; color waxy; early 
anemia. 

4. With patient in dorsal position 
symmetrical enlargement of abdomen, 
bulging in flanks and flat on top. 

5. With patient sitting the abdomen 
bulges below. 

6. Navel prominent and thinned. 

7. Fluctuation decided and diffuse 
throughout abdomen, but is absent in 
the highest parts. Modified on change 
of position. 

8. Intestines float on top of liquid, 
therefore percussion gives a tympanitic 
note in the upper portions and flatness 
in the flanks when patient is on her 
back. Change in position changes po- 
sition of intestines and of resonance 
to the highest part of the abdomen. 

9. Vaginal palpation shows bulging 
into the posterior cul-de-sac. 

10. Uterus prolapsed, but size and 
mobility unchanged. 



1. No such history 

2. Gradual. 

3. Facies ovarina, anemia relatively 
late. 

4. Asymmetrical until tumor is very 
large, peaked on top. 

5. No change. 

6. Navel unchanged usually. 

7. Less distinct and limited to the 
cyst. Not modified by change in po- 
sition of patient. 

8. Intestines occupy same position 
all the time. No change in percussion 
with change in position of patient, i.e., 
flat over cyst and resonant above it 
and to one side, the side opposite to 
that from which the cyst sprung. 

9. No bulging into the cul-de-sac. 

10. Uterus displaced by the cyst, 
mobility limited by the tumor. 



Encysted ascites, or fluid confined to a limited part of the ab- 
dominal cavity by adhesions, may give the same areas of dullness 
and resonance as an ovarian cyst. 



LARGE OVARIAN TUMORS 






3. Fibroids. — There Is considerable danger of confusing a large 
fibromyoma of the uterus with a large ovarian cyst. The following 
table, compiled from several authors and from my own experience, 
points out the chief features in the differential diagnosis: 



Large Uterine Fibroid. 

1. Menorrhagia or metrorrhagia 
common where the growth is intersti- 
tial in part. 

2. General health not necessarily im- 
paired, except anemia from loss of 
blood or debility from pain. Palpita- 
tion of heart common. 

3. Rarely occurs in early life. 

4. Slow growth. 

5. Apt to be asymmetrical and nodu- 
lar; tumors commonly multiple. 

6. Consistency firm, elastic, or hard. 

7. Uterus large and cavity enlarged 
if growth is interstitial. Tumor a part 
of uterus or connected by a short and 
thick pedicle. 

8. Uterine bruit by auscultation in 
half of the cases. 

9. No change in facial expression un- 
less pale from hemorrhage. 

10. Superficial veins of abdomen not 
enlarged. 



Large Ovarian Cyst. 

1. Menstruation unchanged or dimin- 
ished in amount. 

2. General health impaired early. 

Xo pain except in the case of adhesions, 
or other complications. Palpitation 
uncommon. 

3. May occur in infancy. 

4. More rapid growth. 

5. Symmetrical; may be tabulated. 

6. Fluctuating. 

7. Uterus not enlarged. Tumor con- 
nected with it only by pedicle, which is 
apt to be relatively Long. 

8. Absent. 

9. Fades ovarina and loss of flesh 

about neck and chest. 

10. Veins enlarged. 



It must not be forgotten that because of degenerative proc- 
esses in a uterine fibroid there may be fluid in the tumor and 
fluctuation will be found, and that in sonic of the ovarian tumors 
with solid contents fluctuation may be absent. As stated before, it 
is never justifiable to tap a tumor, a procedure once much in vogue 
for the purpose of diagnosis, because sonic of the fluid is almosi 
sure to escape into the peritoneal cavity and to cause peritonitis 
of a grade and severity depending on the character and amount 
of fluid extravasated. 

4. Accumulation of Gas or Fecal Matter in the Intestines. I 
panites has been mistaken for ovarian cyst. Accumulated 
gives a tympanitic note on percussion, the gurgling of gas in tin- 
bowels may be heard by auscultation, and there is an abscm 
a fluid wave on palpation. By the vaginal tour!, there i 



310 DIAGNOSIS OF DISEASES OF THE OVARIES 

absence of the firm elasticity communicated by a fluid or solid 
tumor. In the case of fecal accumulation there is a history of 
chronic constipation and the distended bowel will pit on pressure 
by abdominal or vaginal touch. Active catharsis removes the 
tumor. 

5. Fat or Tumors in the Abdominal Walls, including "Phantom 
Tumor." — A thick panniculus adiposus may simulate an ovarian 
tumor and, strange as it may seem, well-known surgeons have oper- 
ated for tumor under such conditions. Grasping the abdominal 
walls in the hands, it is possible in most cases to determine that 
the fat is in the substance of the wall rather than in the abdominal 
cavity. Edema of the abdominal walls sometimes simulates 

Central part of abdomen 
Tympanitic 




Fig. 132. — Diagram of a Cross Section of the Abdomen of Ascites, Dorsal 

Position. 

tumor. In this case we expect to find pitting on pressure and 
evidences of edema elsewhere. 

Tumors of the anterior abdominal walls consist of fibromyoma 
of the rectus muscle and cysts of the urachus. They are of un- 
common occurrence. 

Fibromyoma of the Rectus. — Two instances of this have fallen under 
my observation. Both patients were twenty-nine years of age and 
mothers of families. One was seen with Dr. F. W. Johnson, of Bos- 
ton, in consultation, March 18, 1892, and operated upon by him the 
same day in my presence. Here there was a tumor of soft consist- 
ency, the size of a Florida orange, in the left epigastric region. The 
other was a patient operated upon by me October 23, 1896. In 
this case there was a somewhat smaller tumor of harder consistency 
in the right rectus muscle, just below the level of the umbilicus. 



LARGE OVARIAN TUMORS 



311 



Both were entirely extraperitoneal and were pronounced by the 

pathologist to be fibromyoma. 

Cysts of the urachus develop in the normally impervious cord 
which runs from the bladder to the umbilicus. Like the bladder 
itself, a cyst of the urachus represents a persistent portion of the 
allantois. A cyst as large as the urinary bladder, or Larger, may 
form in the course of the urachus. Such a cyst is situated between 
the fascia and the peritoneum on the inside of the abdominal 
parietes, in the median line. It is to be differentiated from an 
ovarian cyst by its absence of connection with the uterus or ii- 
appendages, by the greater area in the abdomen of intestinal 



Formerly dull, 
now tympanitic 




Change in 

line of 



tlatiirss 



Fig. 133. — The Same as Fig. 132, Lateral Position. Showing Change in Situation 
of Areas of Dullness and Tympany. 

resonance, and by the absence of the other signs and Bymptoms 
of ovarian cyst. 

" Phantom Tumor." — Phantom tumor occurs occasionally in 
hysterical women who have the power of contracting the muscles 
of the abdomen so as to form a mass thai simulates an abdominal 
tumor. The muscular contraction can be overcome sometimes 
in these cases by firm pressure of the hands and the tumor then 
disappears. There is exaggerated tympany over the tumor be 
cause the intestines, held by the muscles, form the tumor. In 
many cases it is impossible to make an exact diagnosis without 
etherization, and accordingly it is well to etherize a doubtful 
of phantom tumor or tumor in the abdominal wall. 

6. Cyst of the Pancreas. The situation of the tumor it 
importance in differentiating cysi of the pancreas from ovarian 
cyst. The former develops under themarginof the ribe on thelefl 



312 DIAGNOSIS OF DISEASES OF THE OVARIES 

side and grows from above downward. If the cyst is large the 
liver and stomach may be displaced upward, while the transverse 
colon is depressed under the tumor, the cyst reaching the pelvis 
only exceptionally in the case of very large tumors. Therefore a 
pancreatic cyst can be confused only with high-lying ovarian cyst. 
Pancreatic cysts generally are thin-walled and the fluid is thin, 
consequently fluctuation is marked. The greatest convexity of 
the abdomen is in the neighborhood of the umbilicus. The history 
given by the patient is that the tumor w T as high up under the ribs 
when first noticed, and bimanual examination of the pelvic organs 
shows that there is no connection between the uterus and the 
tumor and that the ovaries are not enlarged. 

7. Tumors of the Spleen, Liver, and Kidneys. — Tumors of the spleen 
originate, of course, in the left hypochondrium, have an oblique posi- 
tion, and a peculiar elastic consistency. Under the influence of de- 
generative processes or the presence of an echinococcus cyst there 
may be fluid in a splenic tumor. Such a condition must be re- 
garded as very unusual, however. In tha case of wandering spleen 
the tumor may be in the iliac fossa, and may be mistaken for an 
ovarian tumor or a kidney. Careful palpation of such a tumor 
with the aid of an anesthetic will show one or more notches in the 
anterior border and perhaps a vertical slit at the hilum. Palpa- 
tion of the kidney regions will show the presence of the kidneys 
in their normal situation. It has been suggested by H. A. Kelly 
(Kelly and Noble, " Gynecology and Abdominal Surgery/' Vol. II., 
p. 597) that by passing a renal catheter and injecting the kidnej^ 
with enough fluid to produce a mild renal colic, the pain will be re- 
ferred to the lumbar region and not to the splenic tumor. Exami- 
nation of the pelvic organs ought to exclude uterus, tubes, and 
ovaries from participation in the tumor. A wandering spleen has 
been known to become lodged in the pelvis and there to obstruct 
the intestine (case of Korte, cited by J. Bland-Sutton, Brit. Med. 
Jour., 1897, p. 132), and J. C. Webster (Jour. Amer. Med. Asso., 
1903, Vol. XL., p. 887) has reported a case of wandering spleen 
that occupied the right iliac fossa. 

Tumors of the liver may be confused with ovarian tumors if 
they reach downward to the pelvis, or if during late pregnancy 
an ovarian tumor has become fixed to the liver by adhesions, so 
that upon involution of the uterus the tumor remains in the upper 



LARGE OVARIAX TUMORS 313 

abdomen. The firm, hard consistency of the liver is more or less 
characteristic, also its sharp lower border, which is placed obliquely 
to the ensiform cartilage and is indented with a notch for the gall 
bladder. Also, all liver tumors move more or less on dee]) respira- 
tion, except accessory lobes, very large tumors, and echlnococcus 
disease. The pelvic organs are investigated and the relation of 
the tumor to the liver tested by moving the tumor about and 
noticing if the liver is moved also. 

Tumors of the kidney are not of frequent occurrence. The most 
common are: hypernephroma and papillary cystoma. Malignant 
tumors affect especially the young and the old. Hematuria is 
present in almost all malignant tumors of the kidney; pain in the 
region of the kidney is a less common symptom. Hypemepk 
is a tumor arising from adrenal tissue but involving the kidney in 
practically all instances. The tumor is lobulated and extends 
toward the median line. It is malignant and has metasti 
most commonly in the lungs and liver. 

Polycystic disease of the kidney consists of a cystic degeneration 
of the kidney parenchyma, and the tumor is like a bunch of grapes. 
Many of these tumors are congenital. Congenital kidney 6k 
is apt to be associated with disease of the ovaries, as the two de- 
velop together in fetal life. Echinococcus cysts develop in the 
kidney in 5.8 per cent of all cases of hydatid disease. The tumor 
grows slowly and forms a smooth, round, movable mass. 

A movable kidney may get as low as the pelvis. Its shape is 
characteristic. Hydronephrosis may accompany renal tumor and 
in this case the urine will show abnormal constituents. 

Cystic tumors or simple cysts of the kidney arise in the outer part of 
the cortex, and may attain great size. Such a cyst is to be differen- 
tiated from an ovarian cyst by its location in the flank, its relative 
immobility, and by its not being connected with the uterine organs 
as proved by the bimanual examination. If the uterine organs are 
normal the differentiation is easier than if they are diseased. 

8. Cyst of the Omentum.— Cysts of the omentum are mostly flal 
and shield-shaped; they are very freely movable, and can b 
tated so that in some cases the posterior portion of the cysl may 
be palpated. They are of infrequenl occurrence, and h is gener- 
ally easy to determine that the cyst has no connection with the 
uterine organs. 



314 DIAGNOSIS OF DISEASES OF THE OVARIES 

9. Echinococcus Cysts. — Echinococcus disease may be confused 
with ovarian tumor especially if it involves structures in the pelvis. 
It has been referred to as occurring in the liver, spleen, and kid- 
neys. In the pelvis it occurs in the following situations according 
to Bland-Sutton (" Diseases of Women," Bland-Sutton and Giles, 
p. 388): (a) The uterus; (b) the mesometrium; (c) the pelvic bones; 
(d) the omentum; (e) the Fallopian tubes. There is no authentic 
case on record of primary echinococcus cyst of the ovary. Large 
tumors may develop in any of the structures named. As a rule, 
they form part of a general invasion of the subperitoneal tissues. 
The colonies are apt to communicate with the vagina, bladder, or 
rectum and the characteristic vesicles escape with the urine or feces. 
Bland-Sutton says, "The clinical recognition of echinococcus cysts 
in the pelvic organs, mesometrium, or bones is sometimes made by 
a sort of ' lucky guess ' when other and more common diseases can 
with certainty be excluded. Occasionally when a patient seeks 
advice for pelvic trouble, and brings ' vesicles ' which have escaped 
by the rectum, vagina, or urethra, much speculation is spared. 
When the bones are eroded and swellings form under the skin, 
they are punctured, and characteristic fluid with vesicles and 
hooklets escapes, and so the diagnosis is established. When the 
cysts suppurate the physical signs are those of abscess." 

10. Dilated Stomach. — Careful percussion of the stomach area, 
auscultation of the abdomen while the patient swallows a mouth- 
ful of water, the appreciation of a gurgling sound all over the region 
occupied by the stomach, and the situation of the maximum of 
enlargement of the abdomen above the umbilicus, ought to deter- 
mine the presence of a dilated stomach. If there is a doubt ad- 
minister an effervescent mixture and practice percussion when the 
stomach is distended with gas. 

11. Distended Urinary Bladder. — The bladder may rise as high 
as the umbilicus when overdistended and may present the appear- 
ance of an ovarian cyst. (See Fig. 85, page 217.) The bladder 
tumor is in the median line, close held to the back of the arch of 
the pubes; it bulges into the vagina, distending the anterior wall; 
there is almost continuous overflow of urine, and generally hypo- 
gastric distress, except where the patient is unconscious or the 
distention has existed a long time. Passing the catheter removes 
all doubt. 



COMPLICATIONS OF OVARIAN TUMORS :',!." 



Diagnosis of the Complications of Ovarian Tumors 

The complications to which ovarian tumors arc subject arc: 

1. Adhesions and incarceration. 

2. Intraligamentous development. 

3. Torsion of the pedicle. 

4. Infection and suppuration. 

5. Degenerative processes, including malignancy. 

6. Rupture. 

7. Association with pregnane}-. 

i. Adhesions and Incarceration. — Adhesions between an ovarian 
tumor and its surrounding structures make the diagnosis much 
more difficult, especially in the case of small ovarian tumors, those 
lying wholly within the cavity of the pelvis. The history of at- 
tacks of inflammation may give a clew to the presence of adhesions, 
as the occurrence of pain. It is a well-known fact that the parietal 
peritoneum rather than the visceral peritoneum is the seat of 
pain. This fact has been demonstrated during abdominal opera- 
tions performed under local anesthesia. Therefore we should 
expect adhesions to the parietal peritoneum to cause more pain 
than those to the viscera. Extensive adhesions may occur with- 
out any pain whatsoever. 

Fixation of a tumor to a greater or less degree indicates adhesions 
as a rule. The exception is the rare condition of incarceration 
without adhesions. A tumor may become incarcerated in the 
pelvis, thus causing obstruction of the bowel, or abortion as in the 
case of the retroflexed pregnant uterus. 

An attempt should be made to dislodge an ovarian tumor fixed 
in the pelvis, by putting the patient in the knee-chesl position, 
letting air into the vagina by means of the Sims speculum, and h\ 
making traction on the cervix with a tenaculum. Upward pressure 
on the tumor, the patient being in the dorsal position, through 
either the vagina or rectum will, in many can-, dislodge a non- 
adherent tumor. After reposition the bimanual palpation .-in. I the 
mapping out of the pedicle proceed with greater facility. Some- 
times the shape and character of adhesions in the pelvis can !><• 
made out by touch, also adhesions to the abdominal walls in the 
case of large tumors can be determined in a smaller proportion of 



316 



DIAGNOSIS OF DISEASES OF THE OVARIES 



cases. Adhesions to the intestines, omentum, liver, or spleen can 
not be diagnosed with certainty. 

2. Intraligamentous Development. — If a tumor has grown between 
the layers of the broad ligament it is immovable and can not be 
displaced into the abdominal cavity by bimanual manipulation. 
It gives the impression of being closely united with the uterus and 
the examiner may receive the impression that he has to do with a 
fibroid tumor of the uterus. Intraligamentous tumors are gen- 
erally cystic, however; they have no pedicle and sometimes may 
be differentiated from parovarian cysts by this characteristic. 

If the physician can decide that an immovable cystic tumor in 
the pelvis is connected not only with the uterus but with the side 




ml 
ligament 7 ' 



Fig. 134. — Diagram Showing the Course of the Utero-sacral Ligaments in the 
Case of a Retro-peritoneal Tumor. 



of the uterus the tumor is probably an intraligamentous ovarian 
cyst. This may be done sometimes by grasping the uterus and 
palpating it separately from the tumor. The uterus is commonly 
displaced laterally to the side of the pelvis opposite to that 
occupied by the tumor. Occasionally the ovary with its long 
Fallopian tube stretching to it as a cord may be made out lying 
on the top of the tumor, and now and then the round ligament 
can be palpated as a round cord coming over the surface of the 
tumor to the internal abdominal ring. 

To distinguish a tumor developing under the peritoneum in the 
back of the pelvis from an intraligamentous tumor one tries to 
palpate the utero-sacral ligaments. If these are in front of the 
tumor it is a retro-peritoneal growth, whereas if the ligaments 



COMPLICATIONS OF OVARIAN TUMORS 



317 



are behind the tumor it is an intraligamentous neoplasm. 
Figs. 134 and 135.) 

3. Torsion of the Pedicle. — Rotation of an ovarian tumor on it- 
long axis causing twisting of its pedicle is by no means an uncom- 
mon happening. It presupposes the absence of adhesion- to sur- 
rounding fixed structures such as the pelvic walls or the parietes 
of the abdomen. It is more apt to occur in tumors of medium size. 
To detect a twisting by palpation of the pedicle where all the con- 
ditions are most favorable is a possibility. Ordinarily torsion is 
diagnosed only by its results. The twisting may be gradual, in 
which case the tumor adjusts itself to the lessened blood supply 
caused by the constriction of its pedicle, or it may be rapid. 




Urej-0-sa.ctrd 
-/-Uterus. 



Fig. 135. — Diagram Showing the Course of the Utero-sacral Ligaments in tb 

Case of an Intra-ligamentous Tin nor. 



Whether gradual or rapid there comes a lime when the blood supply 
is cut off, then ensue in the cyst edema, enlargement, suppuration, 
or even gangrene. Atrophy has been known to occur in the case 
of very small tumors and complete separatiou of the cysl from it- 
pedicle in rare instances. Torsion is apt to be followed by adhe- 
sions, especially adhesions to the bowels. 

Symptoms of the chronic stage of torsion may be entirely want 
ing, or a patient may complain of pains in the abdomen especially 
at the time of the catamenia when congestion of the pelvic organs 
is normally greatest . These pain- may be associated with nausea 
and vomiting and are apt to follow viol, nt exertion or trauma. U 
the twisting is sufficient to cause blood stasis the symptoms are 
those of general peritonitis and there is present an acute abdominal 



318 DIAGNOSIS OF DISEASES OF THE OVARIES 

emergency. Acute abdominal pain, rapid, feeble pulse, vomiting, 
elevation of temperature, and a rigid abdomen occurring in a woman 
known to have an ovarian tumor are symptoms calling for im- 
mediate operation. 

Twisting of a pedicle of an ovarian tumor has been mistaken 
for appendicitis. Bimanual examination will reveal the presence 
of the ovarian tumor; the pain caused by torsion is not of the colicky 
character of the pain of appendicitis. Finally the history reveals 
no similar attacks of pain and no history of digestive disturbances 
and irregularity of the bowels as in the case of appendicitis. 

4. Infection and Suppuration. — Infection of ovarian tumors with 
streptococcus, typhoid bacillus, or bacterium coli communis, is 
transmitted by the blood current, or from the intestine, urinary 
bladder, or the Fallopian tube. Formerly, when it was the custom 
to tap ovarian cystomata, infection was introduced very frequently 
in this way. Ovarian cysts become infected following an attack 
of typhoid fever, and in this case the bacilli, in all probability, gain 
entrance through the blood. A patient known to have an ovarian 
cyst should be watched carefully for evidence of infection of the cyst 
following an attack of typhoid fever. The symptoms are chills, 
elevation of temperature, rapid pulse, pain, and tenderness in the 
abdomen. 

The Fallopian tube is a very frequent carrier of infection to an 
ovarian tumor. This is to be inferred because it is about the 
fimbriated end of the Fallopian tube that the densest adhesions 
are to be found during operation for the removal of infected cysts. 
It is probable that infection following puerperal fever reaches a 
tumor by this channel. In the case of an inflamed bladder or in- 
testine or vermiform appendix the organ may become adherent 
to a tumor and the inflammatory process be carried to the growth 
by continuity. The inflammatory process, however transmitted, 
may go on to suppuration. In this case there are to be noted 
sudden enlargement of the cyst, severe pain and tenderness, rapid 
and weak pulse, and chills, high temperature, and exhaustion. 
Prompt operation alone will prevent rupture or general peritonitis 
and death. Gas may be formed in the cyst and then a tympanitic 
note will be given to the percussion over it. 

5. Degenerative Processes Including Malignancy. — The following 
secondary changes may take place in an ovarian tumor, although 



COMPLICATIONS OF OVARIAN TUMORS 319 

none of them can be diagnosed with certainty. On account Of the 
necessity of speedy operation indications of malignancy require 
special attention, however. 

(a) Calcareous degeneration. 

(b) Fatty degeneration. 

(c) Myxomatous degeneration. 

(d) Changes in the fluid contents from straw color — with specific 
gravity of from 1010 to 1050 — to thick or semisolid, of various 
colors and consistencies. 

(e) Malignant degeneration. Carcinoma, sarcoma, endothe- 
lioma, and teratoma are the malignant processes affecting ovarian 
tumors. Suspicion of malignity attaches to double-sided tumors, 
i.e., tumors of both ovaries, and to partial development in the 
broad ligament. Ascites is common in the case of malignant 
tumors, and is apt to be small in amount except in the late stages 
of the disease. Malignant tumors, except sarcoma, are most apt 
to occur in old rather than in young women, and cachexia is found 
in the later stages only. Early edema of the legs in the case of small 
tumors is said to be a sign of malignancy. When the disease has 
attacked the surface of the tumor hardness of the tissues and a 
nodular feeling by both abdominal and vaginal palpation is most 
characteristic. The nodules or lumps may be large or small. 
The surface is irregular. It should not be forgotten that cancer 
of the ovaries is very often metastatic and that the primary seat 
of the disease should be sought in the stomach or intestine. 

6. Rupture. — Rupture of an ovarian cyst is of unusual occurrence, 
especially in these days of relatively early operation on women 
who have tumors. In the older, preaseptie days, when the danger 
of operation w r as great, many cysts ruptured and filled again or 
caused peritonitis as it happened. The physician and also the 
nurse should remember that a thin-walled cysl or one having weak 
places in its walls because of degenerative processes may be rup- 
tured by a too vigorous bimanual examination or by preparations 
for an abdominal operation. Both of these accidents have occurred 
in my experience. In the case of a multilocular cysl only one 
loculus may rupture and the rupture may be into the main 
cavity, into another loculus, or into any one of the following struc- 
tures: peritoneal cavity -mosl frequenl ami bladder, vagina, or 
rectum. Rarely rupture has occurred into the -mall intestine, or 



320 DIAGNOSIS OF DISEASES OF THE OVARIES 

Fallopian tube, and very rarely through the abdominal wall or into 
the stomach. The causes of rupture are, degenerations of the cyst 
wall; papillomatous growths penetrating the wall; torsion of the 
pedicle, causing hemorrhage or suppuration in the cyst with in- 
creased tension ; and trauma, such as blows on the abdomen, care- 
less handling, already referred to, or contractions of the abdominal 
walls in labor. Parovarian cysts when once ruptured may not 
refill. In the case of ovarian cysts the wall continues to secrete 
fluid after rupture and the cyst may refill or the fluid may be 
poured into the organ into which the opening has been made. 
If the fluid is clear and serous it may cause little irritation of the 
peritoneum; if, on the other hand, it is colloid or dermoid in char- 
acter it is apt to- set up a lively peritonitis. The gravity of rupture 
depends then, in large measure, on the character of the cyst con- 
tents. This being unknown, the complication must be regarded 
as serious and treated by immediate operation, for rupture of an 
infected cyst into the peritoneal cavity is usually fatal. 

The symptoms are severe pain in the abdomen, faintness, rapid 
pulse, perhaps subnormal temperature. Examination shows ab- 
sence of the tumor and free fluid in the peritoneum, or discharge of 
fluid from bladder, vagina, or rectum, or other viscus. If only one 
loculus has been ruptured the tumor will be diminished in size 
only by so much. 

7. Association with Pregnancy. — Small or medium-sized tumors 
are more often found in association with pregnancy. Because of 
the danger of rupture and torsion of the pedicle, the diagnosis 
of pregnancy in these cases is of the greatest importance. In the 
early months it is a question of determining the presence of more 
than one growth in the pelvis or a tumor on each side, one being the 
uterus and the other the ovarian tumor. The signs of pregnancy 
are referred to in Chapter XXII., p. 420. If physicians would 
make it a rule to examine all pregnant women under their care 
from time to time with reference to the detection of tumors and 
other abnormalities, many of the tragedies of the puerperium 
would be avoided. In cases of doubt it is advisable to administer 
ether in order to make a diagnosis. 



PATHOLOGICAL VARIETIES OF OVARIAN TUMORS 321 



Diagnosis of the Different Pathological Varieties of 

Ovarian Tumors 

The different kinds of ovarian tumors according to their patho- 
logical characteristics are shown in the list on page 291. Prognosis 
and treatment depend in a measure on the kind of tumor present ; 
therefore, certain probabilities may be stated as to the different 
tumors. The following description is taken with few changes 
from Winter's " Gynaekologischen Diagnostik," p. 303. 

i. Follicular cysts never occur larger than a base-ball. They arc 
unilocular, have thin walls, and are not tightly distended, so thai 
fluctuation can be elicited easily. They are generally unilateral 
and do not cause pain. 

2. Cysts of the corpus luteum arc not larger than a base-ball; they 
have thick walls, and are unilateral. 

3. Simple cysts have thin walls and thin fluid contents, and a it- 
differentiated clinically from follicular cysts only by their greater 
size. 

4. Multilocular cysts are the most common kind of ovarian 
tumors. They vary in size from very small to enormous. In the 
beginning such a tumor is round, but becomes irregular in shape 
by the development of several cysts within the parent cyst. There- 
fore, the surface becomes lobulated and in some cases the large 
and small daughter cysts can be palpated. The consistency 
varies according to the fluid contents. Hard portions are apt to 
be found in the walls where there lias been no cystic degeneration. 
The small or multilocular tumors an; fairly movable; the larger 
ones are limited in motion by adhesions, which are common, 
especially to the omentum, bowel, and abdominal wall, seldom to 
the uterus or other pelvic organs. These tumors are usually uni- 
lateral and have a well-marked pedicle. Ascites is generally absenl : 
when present it is in small amount. 

5. Proliferating papillary cysts are seldom larger than a man's 
head. They are not often perfectly round in shape and have an 
uneven, lumpy surface. In the situations where the papillary 
masses occur the consistency is not so fluid as elsewhere, fne 
tumors are apt to affect both ovaries double tumor: they are ol 
intraligamentous development, at leasl on one side, and arc - 

21 



322 DIAGNOSIS OF DISEASES OF THE OVARIES 

partially, but not entirely, in the broad ligament. When the 
papillary masses have pierced the wall of the tumor there are 
metastases in different parts of the abdomen, especially in Doug- 
las' cul-de-sac. Ascites is common. 

6. Primary carcinoma, when small, retains the form of the ovary; 
when large, the tumor has a surface that is very rough because of 
knobs and excrescences. Small tumors are hard, large ones are 
cystic because of degenerative processes inside. The pedicle is 
for the most part short, and the tumor may be intraligamentous. 
The tumors are generally double and ascites is commonly present. 
Early edema of the legs is to be looked for in the case of small 
tumors, and cachexia in the late stages. Metastases occur early. 
Secondary carcinoma attacking a cyst has the same characteristics. 

7. Dermoids are seldom larger than a man's head and most often 
between a hen's egg and a Florida orange in size. They are round 
and oval in shape and are seldom double, having for contents 
thick fluid, fat, bone, and hair ; fluctuation is not marked. Some- 
times bone may be felt in the wall of the cyst, and often there are 
portions of solid tissue in dermoid cysts. These cysts are of slow 
development and occur most often in young persons. Adhesions 
are common and occasionally the tumor adheres so closely to the 
intestine that there is gas in the tumor. The x-rays may show 
the bone in a tumor. 

8. Teratomata are apt to be the size of a man's head and occur 
mostly in young subjects. Their consistency is solid, often hard, 
and they may contain nodules of varying consistency. If the 
tumor is malignant there are metastases and ascites. The clinical 
diagnosis can seldom be made. 

9. Fibroma of the ovary is a round or oval tumor, very hard, 
with smooth surface and generally unilateral. It may be as large 
as a man's head and ascites is usually present. Often cystic cavi- 
ties develop in such tumors, and the ascites does not return after 
the tumor has been removed. Fibroma can not be distinguished 
clinically from fibrosarcoma. 

10. Sarcoma of the ovary occurs as fibrosarcoma (spindle-celled 
sarcoma) and as round-celled sarcoma. The former is generally 
double, has a smooth surface and a hard consistency, and ascites 
is present. It is benign, and no metastases are formed. The 
round-celled sarcoma, on the other hand, occurs as a soft, medullary 



PATHOLOGICAL VARIETIES OF OVARIAN TUMORS 323 

tumor with tolerably smooth surface. It is generally unilateral 
and ascites is often present and the tumor may be of considerable 
size. The tumor elements perforate the surface early and in- 
filtrate the neighboring organs, especially the abdominal cavity. 
ii. Peri- and endothelioma have the same characteristics as 
round-celled sarcoma. 



CHAPTER XVIII 

THE DIAGNOSIS OF DISEASES OF THE FALLOPIAN TUBES 

Anatomy and age changes, p. 324. 

Congenital Anomalies, p. 326: Absence of the tubes, p. 326. Accessory 
tubes and ostia, p. 326. Diverticula from the tube, p. 326. Hernia of the 
tube, p. 326. Displacement and elongation of the tube, p. 326. Cyst of 
Morgagni, p. 327. 

Salpingitis, p. 327: Acute, p. 327. Chronic, p. 329. Gonorrheal, p. 330. 
Tuberculous, p. 330. Actinomycotic, p. 332. Echinococcus infection, p. 
332. Syphilitic, p. 332. 

Retention tumors (Sactosalpinx) , p. 332. Pyosalpinx, p. 332. Hydro- 
salpinx, p. 333. Hematosalpinx, p, 334. Diagnosis of Sactosalpinx, p. 335. 

Differential diagnosis of Appendicitis and Salpingitis, p. 336. 

New Growths, p. 337: Polypus, p. 337. Papilloma, p. 337. Embryoma, 
p. 338. Myoma and fibroma, p. 338. Fibromyxoma, p. 338. Carcinoma, 
p. 338. Sarcoma, p. 339. Chorioepithelioma, p. 339. 

ANATOMY AND AGE CHANGES 

The Fallopian tubes are developed from the portion of Miiller's 
ducts lying above the round ligaments, and as they come from the 
same structures as the uterus and vagina they are continuous with 
these organs and their canals, and are parts of one long tube, 
branching, when it reaches the uterine horns, into two tubes. (See 
Fig. 71, page 198.) 

Each tube occupies the free border of the broad ligament. It 
has an average length of four inches (10 centimeters) but may 
vary; sometimes one tube is longer than its fellow. The inner 
third of the tube is narrow and is from one-sixteenth to one-eighth 
inch (2 to 4 millimeters) in diameter; it is called the isthmus. The 
outer two-thirds is larger in diameter, three-eighths inch (7 to 8 
millimeters), is called the ampulla, and ends in the infundibulum, 
or trumpet-shaped depression, in the center of which is the ostium 
abdominale surrounded by the fimbria, or fringes. These fringes 
are extensions of the reduplicated mucous membrane lining the 
tube and are of uneven length. Running from the abdominal 

324 



ANATOMY AND AGE CHANGES 

ostium to the ovary is the tvbo-omrian ligament, traversed by a 
furrow so that it appears to be a long fimbria. This represents 
the uppermost portion of Muller's duct that lias been opened out, 
instead of remaining as a closed tube. The tube is convoluted, 
the isthmus is directed outward and slightly upward; while tin- 
ampulla arches over and descends, so that the infundibulum is 
directed toward the ovary and the fimbriae are in contact with that 
gland. (See Fig. 116, p. 285.) 

The lumen of the tube varies from the diameter of a bristle at 
the isthmus to a quarter of an inch (some 5 millimeters) in the 
ampulla. It is lined with mucous membrane, and covered with 
columnar ciliated epithelium, which is reduplicated and thrown 
into longitudinal folds. These folds become thicker as they ;q>- 
proach the infundibulum and on the abdominal side of the ostium 
are continuous with the fimbria 1 . The tube is composed of un- 
striped muscle fiber, continuous with that of the uterus, and ar- 
ranged in an outer longitudinal layer and an inner circular layer. 
Outside" the longitudinal layer is loose connective tissue between 
it and the peritoneum, which covers two-thirds of the circumfer- 
ence of the tube and is terminated by a sharp edge at the ostium 
abclominale. 

The function of the tubes is to cany the ova to the uterus. 1' 
has been shown by Hofmeier and Mandl (J. Whit ridge Williams. 
"Gynecology and Abdominal Surgery," Kelly and Noble, Vol. 11 . 
p. 132) that there is a current of fluid from the peritoneum, or 
secretion from the tubal mucosa, promoted by the cilia of the tubal 
epithelial cells, from the abdominal ostium of the tube to the 
internal os of the uterus. It has been proved by experiments on 
animals and a few observations on human beings that a few hours 
after coitus spermatozoa can be found in the outer portions of the 
tubes and even on the ovaries, so that it would appear that the 
spermatozoa get into the tubes in spite of the currenl againsl them, 
and that the tube is the normal place of impregnation rather than 
the uterus. Under norma] conditions the fertilized ovum is pa 
along by the cilia to the uterus where it becomes embedded in the 
uterine mucosa. Under abnormal conditions il is arrested in 'I"' 
tube and a tubal pregnancy results. 

At the menopause the Fallopian tubes a1 rophy, becomii 
and narrower and the epithelial element- disapp , '"' 



DISEASES OF THE FALLOPIAN TUBES 

old woman they arc nothing but slender cords, often having no 
lumen. (See Fig. 119, p. 289.) 

CONGENITAL ANOMALIES 

Absence.— Complete absence of both tubes is exceedingly rare 
and occurs only in connection with failure or rudimentary develop- 
ment of t he uterus. Absence of one tube is found in cases of failure 
of development of the corresponding uterine horn. Partial de- 
velopment of the tube is more comman than complete absence, the 
tube being represented by a narrow, impervious cord, or a portion 
of t he t ube only may be implicated, and the isthmus may be normal 
while the ampulla is undeveloped or atypical, or vice versa. The 
diagnosis can not be made without an abdominal operation. 

Accessory tubes have been described not infrequently. Probably 
many of them are not true cases of extra tubes but accessory ostia, 
a much more common condition. Three reporters at least have 
given instances of true double tubes, and Nagel (VehVs " Handbuch," 
Bd. I.) found a double Miillerian duct in a human embryo. 

Accessory ampullae communicate with the main lumen of the 
tube, usually entering near the attachment of the mesosalpinx. 
Each has its own infundibulum and fimbriae. As many as six 
accessory ostia have been reported; one or two are not uncommon. 

Diverticula of the walls of the tube appearing as hernise occur 
occasionally, and, like the supernumerary ostia, are of importance 
because they may be lodging-places for fertilized ova, and thus a 
cause of tubal pregnancy. This anomaly, as also the preceding, 
can not be diagnosed except at operation. 

Hernia. — The tube is found sometimes with the ovary in a hernial 
3ac. Such herniae are generally of the inguinal variety and uni- 
lateral. The condition is not susceptible of diagnosis before opera- 
tion. 

Displacement and elongation of the tube may be congenital or 
acquired. The tube is displaced to a greater or less degree with 
displacements of t he ovary and uterus, and also, in the case of large 
ovarian tumors and large tumors of the broad ligament, it is both 
displaced and elongated. In pregnancy it becomes lengthened 
enormously as the uterus approaches its size at full term and after 
labor the lube involutes with the uterus to regain its normal size. 



SALPINGITIS 327 

Sometimes, where the conditions for examination are most 
favorable, i.e., very thin abdominal walls or separation of the recti, 
it is possible to palpate an elongated Fallopian tube coursing over 
a tumor or at the side of a pregnant uterus. Generally the diagnosis 
can not be made. 

The cyst or hydatid of Morgagni is a small cyst rarely larger than 
a pea, attached by a stalk one to one and a half inches (some 2 to 6 
centimeters) long, to the fimbriae or to the tube itself. It is en- 
tirely harmlesss and ha no clinical importance. 



SALPINGITIS 

Salpingitis is the chief disease of the Fallopian tubes of interest 
to the practising physician. 

The classification of salpingitis from an etiological standpoint is 
difficult because it is impossible to distinguish the different sorts of 
bacteria that serve as exciting causes. The streptococcus and the 
gonococcus are the two most important microorganisms. It is 
probable that in those cases where the pus in the tubes is ster- 
ile the inflammation was originally of streptococcic origin but 
that the organism has died out. These organisms are transmitted 
to the tubes through the uterus, an endometritis being an almost 
invariable precursor of a salpingitis. The tubercle bacillus is a not 
infrequent cause of salpingitis, and rare causes are actinomycosis, 
echinococcus disease, and syphilis. Hemorrhagic salpingitis may 
accompany the exanthemata, and there is a mild catarrhal form of 
salpingitis and perisalpingitis of unknown origin that occurs as a 
complication of uterine tumors. 

It is possible for fluids injected into the uterus to pass into the 
tubes, especially when the tubes have been hypertrophied by 
pregnancy and when the normal tonus is not present, and thus set 
up a salpingitis, though this is an academic affair. The lumen of 
the isthmus of the tube is very small and the irritation caused by 
foreign fluids sets up a contraction of the circular fibers so that it is 
seldom that fluid can be made to pass through. 

Salpingitis may be divided clinically into acute and chronic. 

Acute Salpingitis. — Pathology. — In the case of catarrhal salpingitis, 
in the early stages of an acute attack the mucous membrane is 



328 DISEASES OF THE FALLOPIAN TUBES 

swollen so that the redundant folds fill the lumen of the tube. The 
muscular and peritoneal coats are involved to a greater or less 
degree and the entire tube is reddened; the tissues are edematous 
and soft. According to the character of the infecting agent the 
inflammatory process extends or does not to the ovary and neigh- 
boring structures of the peritoneum through the ostium abdom- 
inale. Apparently sometimes the swelling of the mucosa in the 
tube is sufficient to close the ostium and the disease is limited to 
the tube itself. In the tube accumulates a certain amount of serous 
fluid, drainage into the uterus being interfered with by the swelling 
of the mucosa in a very small canal. 

In the case of purulent salpingitis all the processes are intensified. 
The mucous membrane is more swollen and injected; the entire 
tube is much enlarged and there is pus in its canal. The peritoneal 
covering of the tube is involved, and, either by direct extension of 
the inflammation through the wall of the tube, or because of the 
action of the pus that escapes from the ostium of the tube, ad- 
hesions of the ampulla to surrounding structures, — bowel, omen- 
tum, bladder, or uterus, are formed. The mesosalpinx and broad 
ligament are infiltrated so that they have a board-like feeling. 

Symptoms. — The symptoms of acute catarrhal salpingitis are so 
slight that they are overshadowed by the symptoms of the co- 
existing endometritis. (See page 174.) The symptoms of acute 
purulent salpingitis, on the other hand, are often severe, consisting 
of abdominal pain, fever, rapid pulse, uterine hemorrhage, dysuria 
and painful defecation, and purulent vaginal discharge. Accord- 
ing to the amount of localized peritonitis are the symptoms more 
urgent. Where the infection involves the ovary and a tubo- 
ovarian abscess results the symptoms and signs are those of pelvic 
abscess. (See page 193.) 

Diagnosis. — The history is that of endometritis (see page 174) 
and preceding infection. In the catarrhal form palpation by the 
bimanual touch may reveal tenderness of the tube, but this is a 
fine point in diagnosis. In the purulent form, not only tenderness 
but thickening of the tube may be evident. It is especially to be 
cautioned that the utmost gentleness be used because of the danger 
of expressing pus from the ostium of the tube into the peritoneal 
cavity. 

Evidences of endometritis arc also present. If there is much 



SALPINGITIS 329 

distention of the tube in the subacute stage the tube may be made 
out as a sausage-, club-, or retort-shaped body, and it is apt to be 
in the cul-de-sac of Douglas. (See Pyosalpinx.) Acute purulent 
salpingitis is a very common affection and the attempt should be 
made to diagnose the disease early in its course. 

Chronic Salpingitis. — Pathology. — Chronic salpingitis results from 
an acute salpingitis. The tube is usually closely adherent to the 
ovary and surrounding structures; it is apt to be in the cul-de-sac 
of Douglas; it shows marked convolutions and twists. The walls 
of the tube are generally thickened and indurated. Sometimes 
the thickening is in the isthmus, and at others in the ampulla. 
Now and then one finds nodules the size of a small pea in the struc- 
ture of the wall of a tube (salpingitis nodosa), these being found 
generally in the isthmus. On section they show a dense fibro- 
muscular structure containing glandlike spaces, which sometimes 
represent the lumen of the tube. Tubes containing these nodes are 
apt to be impervious. The condition is not to be confused with 
nodular tuberculosis of the tube. 

The ostium of the tube is commonly closed by peritonitic adhe- 
sions or exudate in cases of chronic purulent salpingitis, but often 
on separating the adhesions it will be found that the fimbriae are 
free and the ostium is patent. It is probable that these are the 
cases in which, upon the subsidence of the inflammation and the 
absorption of the exudate in the peritoneum, the ostia become 
pervious again. In many cases, especially those due to gonococcus 
infection, the fimbriae are found adherent and there is true occlusion 
of the ostium. 

In the case of chronic salpingitis infection from the tube may 
be transmitted to the ovary, and a tubo-ovarian cyst or tubo- 
ovarian abscess may result, or the process may be limited to the 
tube, salpingitis proper. 

Symptoms and Diagnosis. — The symptoms are pains in the groins, 
a sense of weight in the pelvis, exacerbations of fever, irregular- 
ity of menstruation, dysmenorrhea, and vaginal discharge. The 
diagnosis is made by palpating enlarged tubes, by the presence 
of preceding and coincident endometritis, and by symptoms of 
pain and fever not accounted for by the endometritis. 

Salpingitis due to the streptococcus is less apt to affect both 
tubes than is the gonorrheal variety. 



330 DISEASES OF THE FALLOPIAN TUBES 

Gonorrheal Salpingitis. — As a rule it is a long time, months or 
years, before the gonococci of an endometritis reach the tubes, 
although they have been found in the tubes within two weeks 
after the initial infection; therefore the disease is generally de- 
scribed as being subacute or chronic from the start. 

The disease is usually bilateral and may be ushered in by a chill, 
fever, and local tenderness and pain. In the more chronic stages 
the amount of tenderness is variable and may be wanting, there 
is generally no fever, and the patient may be in fair health 
except for anemia and debility; but during the menstrual 
periods there are dysmenorrhea, local tenderness, irregularities 
of menstruation, and increased vaginal discharge as troublesome 
symptoms. Acute attacks of inflammation are apt to occur in 
the history of chronic gonorrheal salpingitis and whenever a 
drop of pus escapes into the peritoneal cavity there is inflam- 
matory reaction. 

As previously stated, the ostia of the tubes are more apt to be 
closed by gonorrheal than by streptococcic inflammation, thus 
accounting for the sterility of prostitutes. 

Diagnosis. — Unless the gonococci can be found in the discharges 
from the uterus there is no way of distinguishing this form of 
salpingitis from any other. The probabilities may point in this 
direction from a history of gonococcus infection, from the occur- 
rence of gonorrheal joint affections, or from evidences of past 
inflammation in the vaginal or inguinal glands. 

Tuberculous Salpingitis.— The Fallopian tube is the most frequent 
site of genital tuberculosis in the female. Where careful routine 
microscopical investigations have been made of all the clinical 
material furnished by the operating-rooms of hospitals it has been 
found that from five to ten per cent of all the inflammatory affec- 
tions of the tubes are tuberculous. Without painstaking investiga- 
tions it is impossible often to distinguish tuberculous from simple 
salpingitis. 

The disease may be primary in the tubes (it is generally bilateral) 
or secondary to a lesion or lesions at a distance, as in the lungs, or 
in a contiguous organ, such as a tuberculous ulcer of the intestine. 
The tubercle bacillus may come to the tube from the vagina by 
way of the uterus, or from the blood current. The infection may 
be limited to the tubes, or both uterus and tubes are involved. 



SALPINGITIS 331 

It is possible, and not a very uncommon happening, for the gono- 
coccus to be associated with the tubercle bacillus. 

Pathology. — Tuberculosis of the tubes appears in three forms, 
miliary, caseous, and fibrous. The appearances of the tube vary 
according as the disease began in the mucous membrane lining 
its cavity or in the peritoneal coat. The tube may be atrophied 
or much enlarged and tortuous and a part or the entire tube may 
be affected. Microscopically tuberculous nodules are found. These 
consist of a central giant cell surrounded by epithelioid cells and 
an outer zone of small round cells. Caseous foci are common and 
the folds of the mucosa are thickened and adherent. The lumen 
of the tube may be closed by a hyperplastic process affecting the 
mucosa just as ir the swelling which accompanies infections by 




K 




Fig. 136. — Tuberculous Salpingitis. (Dudley.) 

other organisms. The disease generally is progressive, but may 
be arrested, the tube being represented in such cases by a thin, 
impervious, fibrous cord. If the disease progresses one expects to 
find tuberculosis of the peritoneum. 

Diagnosis. — Tuberculous salpingitis is seldom seen in an early 
stage when the diagnosis can be only that of salpingitis. A 
tuberculous history or tuberculosis elsewhere in the body leads one 
to suspect the etiological significance of a salpingitis and some- 
times in the later stages fluid in the peritoneum calls attention to 
tuberculosis. Pyrexia, recurring every evening and disappearing 



332 DISEASES OF THE FALLOPIAN TUBES 

every morning, loss of weight and strength, rapid pulse, sweating, 
particularly at night, are symptoms of tuberculosis. 

Actinomycotic salpingitis is secondary to actinomycosis elsewhere, 
besides being very rare. The tubes are converted into abscesses 
in which the characteristic yellow or brownish-black, sago-like 
granules are readily recognized. Under the microscope the acti- 
nomyces is recognized in the characteristic granulation tissue. 

Echinococcus infection is extremely rare also, and is secondary to 
hydatid disease in the broad ligament or elsewhere in the pelvis. 
Sometimes, but not always, pelvic hydatids are secondary to 
hydatid disease of the liver or other abdominal organ. Cases 
have been reported of tubes enormously distended by hydatids. 
The diagnosis would rest on the discovery of the disease in some 
neighboring organ or the passage of cysts from the vagina, rectum, 
or bladder. 

Syphilitic salpingitis must be regarded as a very rare disease. 
It has been found in the new-born and extremely rarely in the 
adult. The tubes contain miliary gummata in their walls, and the 
folds of the mucosa are adherent. In one case in an adult, gummata 
the size of hazelnuts were found. The diagnosis is made probable 
by finding evidences of syphilis in other situations in the body, 
by the history of syphilis, and by the presence of an enlarged tube. 



RETENTION TUMORS OF THE TUBE, OR SACTOSALPINX 

Pyosalpinx is a Fallopian tube distended with pus. The tube 
varies in size and shape. With moderate distention it is club- 
shaped, having a number of convolutions ; with more distention it 
is retort-shaped with the stem of the retort at the uterine horn; 
here the convolutions are more or less eliminated. With extreme 
distention the tube becomes an oval sac. These large tubes are 
uncommon. The largest ones I remember having met were in the 
case of a woman twenty-three years old, upon whom Dr. Clement 
Cleveland operated with my assistance January 20, 1890. The 
patient had been married one year and had not been pregnant. 
She had very few symptoms. The right tube measured six inches 
in length, and three inches in diameter at its outer end, and one 
mikI three-fourths inches at its inner end. Three inches of the 



RETENTION TUMORS OF THE TUBE 



333 



isthmian end of the tube were not enlarged. This tube had com- 
paratively few adhesions about it. The left tube measured four 
inches in length, and three inches in diameter, and the surrounding 
adhesions were dense. Each was ovoid in shape and showed no 
convolutions. 

As a rule a pus tube is surrounded by adhesions, because its 
peritoneal surface is enveloped in an inflammatory membrane. 
The pus is sterile in over half of all cases. This fact is explained by 
the dying out of the microorganisms which have caused the inflam- 
mation and are always to be found in the acute and subacute cases. 
The walls of a pyosalpinx are generally thick, but they may be thin. 




Fig. 137. — Pyosalpinx. 



In the older cases the epithelial lining of the tube has been replaced 
by granulation tissue. Rupture into the peritoneal cavity is an 
accident which has occurred, although not very commonly. C. W. 
Bonney {Surgery, Gynecology, and Obstetrics, Nov., 1909, p. 542) 
collected forty-five cases, including the cases from the literature 
and a case of his own. In most instances there was no assignable 
cause for the rupture. Whenever infection has set up an abscess 
of the ovary as well as a pyosalpinx the condition is known as a 
tubo-ovarian abscess. This has been described under Pelvic Abscess. 
(See Chapter XII, page 193.) 

The diagnosis of pyosalpinx will be considered with the diag- 
nosis of hydrosalpinx and hematosalpinx. 

Hydrosalpinx is an accumulation of serous fluid in the tube. It 



334 



DISEASES OF THE FALLOPIAN TUBES 



presupposes complete closure of the ostium abdominale, but not 
necessarily the lumen of the isthmus of the tube, and is the result 
of a preexisting salpingitis. In intermittent hydrosalpinx there is 
a temporary obstruction to the uterine outlet of the tube caused 
by kinks in the isthmus, that is, a mechanical stenosis exists. In 
such cases there is a periodic discharge of watery fluid through the 
uterus. The shapes of tubes, the seat of hydrosalpinx, are the same 
as those of pyosalpinx, but the walls are thinner and on micro- 
scopic examination are seen to be practically normal, except in 
the case of follicular hydrosalpinx, in which there are evidences 



/Yormal inner third, 
of tube 




Fig. 138. — Hydrosalpinx, Two-thirds Actual Size. (Author's Case). 



of endosalpingitis. Hydrosalpinx is seldom larger than a Bartlett 
pear, although cases have been reported the size of a child's head. 
The ampulla of the tube is dilated with fluid more often than the 
isthmus. If an ovarian cyst connects with a distended tube by 
an adventitious opening not the ostium abdominale, the condition 
is known as a tubo-ovarian cyst. These cysts are by no means 
uncommon, and can not be distinguished clinically from hydrosal- 
pinx, except in those rare cases of hydro salpinx in which the normal 
ovary can be palpated by bimanual touch. 

Hematosalpinx is a Fallopian tube distended with fluid blood. 
Hemorrhage occurring into a hydrosalpinx forms a hematosalpinx. 
It is now believed that a majority of cases of hematosalpinx are 



RETENTION TUMORS OF THE TUBE 335 

the result of tubal pregnancy and incomplete abortion. (See 
Tubal Pregnancy.) Hematosalpinx presupposes closure of the 
ends of the tube just as in the case of pyosalpinx and hydrosalpinx. 
Hemorrhage into the tube may take place as a result of torsion of 
the tube and it occurs as a complication of fibroids of the uterus. 
It is found also in cases of imperforate hymen with accumulation 
of menstrual blood in the uterus (hematometra). 

Hematosalpinx resembles hydrosalpinx as to size and shape, 
but is of a dark reddish-brown color. The walls are thick, but 



Fig. 139. — Hematosalpinx, Actual Size, Caused by Acute Torsion of Right 
Tube. Twist of Two Turns to the Right at the Isthmus. (Author's Case). 

friable, and covered by adhesions. On microscopic examination 
it is seen that the mucosa is degenerated and destroyed, the muscu- 
lar tissue is swollen and infiltrated, while the peritoneal coat shows 
thrombosed vessels and deposits of blood pigment. 



Diagnosis of Sactosalpinx 

The diagnosis of pro-, hydro-, and hematosalpinx rests on the 
determination by palpation of a tumor of the shape of a dilated 
tube connected with, but not a part of the uterus. If the normal 
ovary can be distinguished separate from the tumor so much the 
better. In the cases where the lube is not very large the charac- 
teristic shapes — club-shaped, pyriform, or retort-shaped — can bo 



336 DISEASES OF THE FALLOPAN TUBES 

made out with clearness. Also in these cases the isthmus of the 
tube connecting the tumor with the uterine horn may be palpated. 
With the larger tubes no characteristic shape can be learned by 
palpation. If both tubes are enlarged it is a strong diagnostic 
point in favor of retention tumors because these are generally 
bilateral. 

Pelvic peritonitis with adhesions is an almost universal accom- 
paniment of these tumors, therefore they are more or less fixed. 
There is no means of knowing previous to operation the contents 
of a dilated tube ; whether pus, serum, or blood. Aspiration is 
not justifiable because by puncturing the tumor its contents may 
contaminate the peritoneum, thus complicating needlessly an 
operation for removal, which is indicated in all cases. 

The diagnosis of rupture of a retention tumor is the same as 
that of rupture of an ovarian tumor (see page 319). 

Torsion to the point of strangulation is evidenced by acute 
stabbing abdominal pain, vomiting, and the signs of a tender 
tumor in the situation of the tube. Torsion without stran- 
gulation has been reported in only three cases. Storer in 1906 
(M. Storer, Boston Med. and Surg. Jour., March 15, 1906, page 
285) reported a case of bilateral torsion and collected sixty-two 
cases of torsion of the tube in the literature since Bland-Sutton 
first called attention to the condition in 1890. 

Differential Diagnosis between Salpingitis and Appendicitis 

Right-sided salpingitis is often mistaken for appendicitis. It 
should be remembered that the two affections may co-exist, 
and in this case which was in the beginning the exciting cause and 
which is the chief factor at the present time, are shown by the clinical 
history of the onset of the attack. Acute salpingitis is usually 
preceded by endometritis, by a vaginal discharge, and by menstrual 
disturbances, often by dysmenorrhea. In the case of appendicitis 
there is a history of digestive disturbances, of irregularity of the 
bowels, or of previous attacks of pain in the right side. Rovsing 
has made use of a method of reproducing the pain of appendicitis 
that is of value sometimes in the differential diagnosis. He strokes 
the descending colon from below upward, and the transverse colon 
from left to right, thus forcing gas back into the cecum and appen- 



NEW GROWTHS 337 

dix, distending these structures and reproducing a pain similar to 
that from which the patient has suffered. 

In salpingitis the pain is more steady, less intense, and radiates 
into the pelvis, while in appendicitis it is colicky and more general. 

Dr. Robert T. Morris (Jour. Amer. Med. Asso., January 25, 1908, 
Vol. L., page 278) has directed attention to two points of tenderness, 
called Morris' points, which he considers of great assistance in 
distinguishing between chronic salpingitis and chronic appen- 
dicitis. One point is situated one and a half inches from the 
umbilicus on a line drawn from the umbilicus to one anterior 
superior spinous process of the ilium, and the other point is in a 
similar situation on the opposite side. These points are approxi- 
mately over the lumbar lymph glands which receive the lymph ves- 
sels from the Fallopian tubes, ovaries, uterus, and broad ligaments, 
and also from the appendix. McBurney's point is on this same 
line on the right side one and a half inches from the spinous process. 
The right Morris' point is tender on pressure in the case of chronic 
appendicitis not involving the Fallopian tube, sometimes even 
when McBurney's point is not tender. In the case of salpingitis 
either unilateral or bilateral both Morris' points are tender. Several 
physicians have reported satisfactory results from the use of this 
means of diagnosis and it may be regarded as an accessory to other 
methods of diagnosis in chronic cases. 



NEW GROWTHS 

Primary new growths of the Fallopian tubes are relatively rare. 
They originate in the mucosa, or in the walls of the tube, and are 
benign or malignant. The benign growths are, polypus, papilloma, 
embryoma, myoma and fibroma, and fibromyxoma. The malig- 
nant growths are carcinoma, sarcoma, and chorioepithelioma. 

Polypus of the mucosa is rare. It consists of simple inflammatory 
thickening of the mucous membrane or a polypus similar to a 
uterine polypus originating from placental tissue left attached to 
the tubal wall by a tubal pregnancy. 

Papilloma is thought to be a result of an old salpingitis rather 
than a neoplasm proper. E. Burdon (" Gynecology and Abdominal 
Surgery," Kelly and Noble, Vol. I, p. 174) has collected fourteen 

22 



338 DISEASES OF THE FALLOPIAN TUBES 

cases from the literature. According to this authority the disease 
consists of a cauliflower papillary mass which originates in the 
mucous lining of the tube and distends the lumen without invading 
the wall. " Small peritoneal papillomata may develop, but metas- 
tases do not occur. Like the ovarian papillomata the tubal 
growths often produce an ascites. If, however, the abdominal 
ostium is closed, there is no ascites and the fluid is either retained 
in the tube or is discharged through the uterus (hydrops tubae 
profluens)." Papilloma of the tube is generally unilateral. 

Embryoma. — There have been at least four authentic cases of 
dermoid tumor of the tube reported in the literature, occurring 
in patients between the ages of twenty-five and forty-eight. One 
of the cases was an oval tumor the size, of a hen's egg, which on 
section showed a tumor mass free in the tubal canal and having 
only a superficial attachment to the mucosa. 

Myoma and fibroma, occurring as small nodules in the tubal walls, 
are not to be confused with the salpingitis nodosa of gonorrhea 
or with the nodules occurring in tuberculosis of the tubes. Bland- 
Sutton says (" Surgical Diseases of the Ovaries and Fallopian 
Tubes," page 286): "1 have satisfied myself that when there is a 
general myomatous enlargement of the uterus, the muscle tissue of 
the tubes also participates in the change, becoming thick and hard." 

A true fibromyomatous nodule similar in every respect to uterine 
fibromyomata and the size of a walnut has been described as 
occurring in the tube. Even larger tumors have been reported. 
They are extremely rare. 

Fibromyxoma. — One case of fibromyxoma of the tube has been 
reported in the literature, the tumor being about the size of a fist. 

Carcinoma. — Hurclon refers to seventy cases of primary car- 
cinoma of the tube in the literature. The disease usually affects 
one tube, though it may be bilateral. It occurs most often in 
women who are between forty and sixty years of age and chronic 
salpingitis is thought to stand in an etiolbgic relation to the disease. 
It originates in the epithelial covering of the mucosa and develops 
in the form of a papillary tumor. The diseased tube is converted 
into a large cylindrical pear-shaped tumor, which may reach the 
size of a child's head, but is usually about the size and shape of a 
retention tumor of the tube. The disease may advance by direct 
extension to the surrounding structures or by metastases. 



NEW GROWTHS 339 

Sarcoma. — There are only five cases of this disease in the lit- 
erature, two round-cell, one spindle-cell, and one myxosarcoma. 
The tumor arises in the connective tissue of the mucous membrane 
or tube wall and presents a papillary or polypoid character. 

Chorioepithelioma of the tube, as a sequence of tubal gestation, 
seems to be relatively as frequent as chorioepithelioma of the ute- 
rus following uterine pregnancy. Hurdon notes eleven cases that 
have been reported. In the place of the tube there is a large sac 
with thin, friable walls, which encloses a soft, spongy structure 
resembling placenta, and masses of bloody, fibrinous material. 
Histologically the findings are the same as in chorioepithelioma 
of the uterus. 

The diagnosis of neoplasms of the tube can be only a probability. 
Fortunately they are very rare. After diagnosing a tumor of the 
tube by palpation, the possibility of its being a neoplasm should 
be borne in mind. 

Tubal pregnancy will be considered in the next chapter under 
Extra-uterine Pregnancy. 



CHAPTER XIX 

THE DIAGNOSIS OF EXTRA-UTERINE PREGNANCY 

Tubal pregnancy, p. 341: Frequency, p. 341. Etiology, p. 341. Pa- 
thology, p. 343. Uterine decidua, p. 344. Fate of the fetus, p. 344. Dis- 
eases of the ovum, p. 345. 

Ovarian pregnancy, p. 345. 

Symptoms and signs of extra-uterine pregnancy, p. 346: Pelvic hemat- 
ocele, p. 347. Multiple, combined, and repeated tubal pregnancies, p. 348. 

Diagnosis, p. 348: Early extra-uterine pregnancy, p. 348. Late extra- 
uterine pregnancy, p. 350. 

Differential diagnosis, p. 351 : Early extra-uterine pregnancy before 
rupture, p. 351. Early extra-uterine pregnancy after rupture, p. 352. Late 
extra-uterine pregnancy, p. 353. 

DEFINITIONS 

By extra-uterine pregnancy we understand the development 
of a fertilized ovum at some point between the Graafian follicle 
in which it originates and the uterus. 

The fertilized ovum may develop on the ovary itself, ovarian 
pregnancy, on the fimbria ovarica, one of the fringes at the ostium 
abclominalc of the Fallopian tube that extends from the ostium 
to the ovary, so called abdominal pregnancy, or in the tube, tubal 
pregnancy. 

It is possible, and cases have been reported, of a fertile ovum 
developing in a tubo-ovarian cyst, the fetal sac being made up 
partly of tubal and partly of ovarian tissue. Such cases are spoken 
of as being tubo-ovarian pregnancies. When a primary tubal 
(ampullar) pregnancy has grown in its development into the abdom- 
inal cavity it is called a tubo-abdominal pregnancy, and when, at 
the opposite end of the tube, a pregnancy beginning in the uterine 
end of the isthmus (interstitial pregnancy) develops into the uterus 
il is referred to as tubo-uterine pregnancy. 

True abdominal pregnancy does not exist, the cases reported 
as such being those in which the growth of the fertilized ovum 

340 



TUBAL PREGNANCY 341 

began on ovarian or tubal structure and the subsequent develop- 
ment was in the abdominal cavity. 



TUBAL PREGNANCY 

A vast majority of extra-uterine pregnancies are tubal, and of 
these the ampullar form is probably the most common, though 
some authors assert that the isthmial variety has the precedence. 
The interstitial variety is the rarest. 

Frequency. — It would appear that extra-uterine pregnancy is 
more frequent than formerly, but whether this is really so or seems 





Fig. 140. — Early Ampullar Extra-uterine Pregnancy. Tubal Abortion. 
Natural Size. (Kelly.) 

to be so because of better diagnosis and the more common practice 
of opening the abdomen, is not plain. In 1876 Parry was able 
to collect only 500 cases from the literature ; to-day the literature 
teems with them. One prominent gynecologist in this country 
has reported recently having seen as many as 300 cases of extra- 
uterine pregnancy, another 200, and a third has operated on 154 
cases. Still another operator says that operations for extra-uterine 
pregnancy form about four per cent of all his abdominal oper- 
ations, and in my own experience such operations have been nearly 
five per cent of all my celiotomies. 
Etiology. — As to the causation of tubal pregnancy we are si ill 



342 



EXTRA-UTERINE PREGNANCY 



in the dark. Dr. J. Whitridge Williams (" Extra- uterine Preg- 
nancy," Kelly and Noble, " Gynecology and Abdominal Surgery," 
Vol. II., page 137), to whom I am indebted for much of the matter 
in this chapter, after reviewing at length the different theories 
which have been advanced to explain its occurrence, says of 
etiology: "In many instances the arrest of an ovum in a crypt 
resulting from follicular salpingitis, or in a diverticulum from 
the lumen of the tube, may afford a satisfactory explanation, 




Fig. 141.— Same Case as Fig. 140. The Mole and the Fetus Have Been Re- 
moved from the Tube. (Kelly.) 

though in a certain proportion of cases even the most careful 
history of the patient and thorough microscopic examination 
of the specimen will fail to reveal a tangible cause for the condition." 
Any woman dining the childbearing age may have extra-uterine 
pregnancy. It is more often observed in women who have been 
previously sterile or when there has been a long interval since 
the last pregnancy . 



TUBAL PREGNANCY 



343 



Pathology. — It appears that the ovum is embedded and the 
placenta is formed in the tube exactly as in the uterus. The tube 
wall is invaded by the fetal elements, its structures become degen- 
erated and in part converted into fibrin so that they offer com- 
paratively little resistance to the developing fetal cells. Shortly 
the latter are found just under the peritoneum. In a majority 
of cases early rupture of the tube is due to the erosion of a large 
blood-vessel with consequent hemorrhage and a giving way of the 
thin peritoneum. 

Tubal pregnancy may terminate by abortion into the lumen 




Fig. 142. — Pelvic Hematocele. 



of the tube, the most frequent issue; by rupture into the peritoneal 
cavity, both of these taking place during the first few weeks of 
pregnancy; or by development even to term. Rupture is more 
common in pregnancy in the isthmus, and abortion in ampullar 
pregnancy. 

As far as the results go it makes little difference whether early 
rupture takes place through the capsular membrane into the 
lumen of the tube or through the wall of the tube. There is a 
hemorrhage in either case. The ovum with its membranes is (1) 



344 EXTRA-UTERINE PREGNANCY 

separated completely from its bed and is expelled into the lumen 
of the tube and perhaps through the ostium, or (2) is expelled 
through the tubal wall directly into the peritoneal cavity or, (3) 
the separation is partial, the ovum remains, and the hemorrhage 
continues. The last, incomplete abortions, are the most frequent. 
When the ovum and its envelopes are extruded at once through 
the ostium abdominale the hemorrhage may cease ; when, on the 
other hand, the separation of the ovum from the tubal wall is 
only partial, the ovum may increase in size because of infiltration 
with blood, and a tubal mole is formed. Under such conditions the 
hemorrhage continues as long as the mole remains in the tube 
and the blood trickles from the ostium and forms a pelvic he- 
matocele instead of free hemorrhage into the peritoneal cavity as 
in the case of complete abortion or tubal rupture. 

Tubal rupture occurs more frequently in isthmial and interstitial 
pregnancy than in ampullar pregnancy. In interstitial pregnancy 
rupture may not occur until as late as the fourth month, whereas 
in isthmial pregnancy rupture generally occurs within the first 
few weeks of pregnancy, not infrequently before the patient is 
conscious that she is pregnant. 

Rupture occurs near the placental site and is either into the 
peritoneal cavity or between the folds of the broad ligament. 

Uterine Decidua. — A decidua, very similar in structure to the 
decidua of uterine pregnancy, is formed in the uterus coincident 
with the development of the ovum in the tube, and it is cast off 
soon after the death of the fetus either in small pieces, or, rarely, 
as a complete triangular cast of the uterine cavity. (See Fig. 143.) 
Hemorrhage from the uterus is apt to occur when the decidua comes 
away, but the membrane may be passed without the patient's 
knowledge. If portions can be obtained for microscopic examina- 
tion, either from discharges or by curetting the uterus, they furnish 
a valuable diagnostic sign. 

Fate of the Fetus. — The extruded ovum is always killed and is 
absorbed by the peritoneum unless it is advanced beyond the 
third month. It is highly improbable, as thought formerly, that 
the placenta can be attached to other structures in the abdominal 
cavity, at this time. The facts go to show that attachment is 
primary either on the ovary or tube and that any other adhesions 
are due to the later stages of the development of the fetus and 



OVARIAN PREGNANCY 



345 



placenta. If the rupture is between the folds of the broad ligament, 
a rare happening, the fetus dies and a hematoma of the broad 
ligament is formed. Exceptionally when the placenta is not 
injured pregnancy may continue in the broad ligament or the 
broad ligament sac may rup- 
ture into the peritoneal cavity 
and a secondary abdominal "preg- 
nancy results. 

If the fetus has developed 
beyond the third month it may 
be mummified, consisting of an 
absorption of the fluid portions 
so that there is nothing left but 
shriveled skin holding together 
the bones of the skeleton, or, 
rarely, it may form a lithope- 
dion, a mummified fetus in 
which lime salts have been de- 
posited. Sometimes the dead 
fetus and its membranes sup- 
purate and an abscess is formed FlG> -uterine Decidua from a 

and Very exceptionally this fetus Case of Extra-Uterine Pregnancy. 

becomes converted into adipo- ( ei e •' 

cere, a sort of ammoniacal soap found occasionally in dead bodies. 

Diseases of the Ovum. — The occurrence of tubal mole has been 
referred to already. (See page 344.) Hydatidiform mole has been 
found in the tube and differs in no respect from hydatidiform 
mole occurring in the uterus. In this situation it is followed by 
chorioepithelioma just as in the uterus. 

In most cases of advanced tubal pregnancy there is a diminution 
in the amount of liquor amnii, but hydramnios has been observed. 
There are two cases on record of patients who had eclampsia 
during false labor. 

OVARIAN PREGNANCY 




J. Whitridge Williams has collected from the literature thirteen 
positive cases of ovarian pregnancy, in eleven of which the preg- 
nancy had not progressed beyond the fourth month. In addition 



346 



EXTRA-UTERINE PREGNANCY 



he classed as highly probable or probable ovarian pregnancy, 
twenty-two other cases. In eleven of these thirty-five cases 
pregnancy had progressed to full term, so that the inference is 
that the ovary can accommodate itself more readily than the 
tube to the growing fetus. Early rupture is the rule, however, 



Amnion 



Partially 
separated 
placenta. 



Uterine 
cavity. 




Cervix 



Fig. 144. — Interstitial Pregnancy. (Bumm). 

in ovarian pregnancy, just as in tubal pregnancy. It is possible 
for the ovum to be destroyed early without rupture and ovarian 
hematoma may result. The implantation of the ovum on, or in, 
the ovary does not differ from the embedding in the uterus except 
that a definite decidua is wanting. 



SYMPTOMS AND SIGNS OF EXTRA-UTERINE PREGNANCY 



There are no symptoms to early unruptured extra-uterine preg- 
nancy and its discovery is only a matter of chance. Slight pain 
in the ovarian region may be present. Amenorrhea may be a 
symptom, but cases are recorded of rupture before it was time 
for another menstrual period, the patient having no idea she was 
pregnant. Suppression of menstruation is not as frequently a 



SYMPTOMS AND SIGNS 347 

symptom with extra- as with intra-uterine pregnancy, perhaps 
clue to the presence of the uterine decidua, and if rupture or 
abortion takes place in the tube there is hemorrhage from the 
uterus. Sometimes the patient thinks herself pregnant and there 
may be present signs in the breasts, bluish discoloration of the 
anterior vaginal wall and the introitus, together with enlargement 
of the Fallopian tube on bimanual palpation. 

It has been my experience that the patient has skipped one 
menstrual period and has some symptoms of pregnancy before the 
symptoms of rupture occur. These are sudden, severe, lancinating 
pain in the groin, bearing down, and rectal tenesmus, followed 
at once by faintness and sighing respiration with collapse, pallor, 
distention of the abdomen, a feeble rapid pulse, and subnormal 
temperature. Patients seldom die of this first hemorrhage, but 
after a few hours there is another attack of pain, followed by greater 
collapse, and if there is no surgical aid death may follow. 

No two cases are alike, one will bleed rapidly and another slowly. 
Further, the amount of collapse does not seem to be in direct 
ratio to the amount of blood which has escaped into the peritoneal 
cavity, for upon operation it is found sometimes that when the 
abdomen is full of blood the symptoms have not been severe. In 
other cases most alarming symptoms follow the extravasation of 
a small quantity of blood. 

Pelvic Hematocele. — If the blood has trickled out of the ostium 
of the tube, as in tubal abortion, or if for any reason the discharge 
of blood is intermittent, there will be a series of attacks of pain, 
perhaps a week or two apart. In these cases a pelvic hematocele 
is generally formed. The blood collecting in the pelvis is partly 
coagulated and is walled off by an organized membrane of perito- 
nitic exudate. Such a collection may be a solitary, or a diffuse 
hematocele, the former term being applied to a smaller collection 
of blood in the neighborhood of the Fallopian tube. 

Local examination shows a boggy mass, also softness of the 
cervix, and pain on moving it forward with the finger. Bluish 
discoloration of the vagina may be present. Colostrum in the 
breasts is an unreliable symptom. In some cases of early rupture 
there is a uterine discharge of a brownish color which may con- 
tinue for weeks. This is due to the disintegration of the decidua 
in the uterine cavity. 



348 EXTRA-UTERINE PREGNANCY 

The pelvic hematocele is generally situated in the cul-cle-sac 
of Douglas. If the uterus happens to be retroverted and the cul- 
de-sac obliterated the blood may be effused in front of the uterus 
and in that case the hematocele will be found anteriorly. A fresh 
hematocele is flaccid and fluctuates; an old one is hard and may 
be of uneven density. 

If rupture does not result in death and there is no surgical 
interference pregnancy may continue and secondary abdominal 
pregnancy may follow. Then the symptoms will be those of preg- 
nancy, with more pain and more suffering from the fetal movements 
than in uterine pregnancy. False labor sets in at term with uterine 
contractions and pain. The fetal sac contains so few muscular 
fibres that it can not contract to any great extent. The false labor 
may last a few hours or a number of days and is followed by the 
death of the child. 

Multiple, combined, and repeated tubal pregnancies are reported 
in the literature. Twin tubal pregnancies occur occasionally, 
both embryos being in the same tube or one in each tube, and 
Sanger and Krusen, according to Whitridge Williams, have reported 
cases of triplet tubal pregnancy, all of the embryos being of the 
same age. Combined extra- and intra-uterine pregnancy is not 
very rare. Weibel in 1905 had collected 119 cases from the lit- 
erature. This class includes only the combined pregnancies in 
which the embryos were of the same age, and not the cases of 
uterine pregnancy occurring in the presence of the remains of an 
old extra-uterine pregnancy. 

There have been many cases on record of repeated tubal preg- 
nancy in the same woman, and several cases of this have fallen 
under my observation. 

DIAGNOSIS OF EXTRA-UTERINE PREGNANCY 

Early Extra-uterine Pregnancy 

The positive diagnosis of early tubal pregnancy before rupture 
lias been made and has been proved by operation. Such a diag- 
nosis is based on the symptoms and signs of early pregnancy and 
the presence of a lender unilateral tumor of the tube and slight 
enlargement of the uterus, more especially if the woman has been 



DIAGNOSIS 349 

sterile, or a long interval has elapsed since the last pregnancy. A 
diagnosis under these conditions is only probable, however. Any 
patient presenting such a combination of symptoms and signs 
should be kept under continued observations until the diagnosis 
is made plain or an operation is performed. The death of the fetus, 
usually between the fourth and the ninth week of pregnancy, is 
signalized by the discharge of the uterine decidua and by more or 
less hemorrhage from the uterus. At this time the diagnosis is 
apt to be uterine abortion. Always carefully examine the ovaries 
and tubes in cases of abortion and if possible get shreds of extruded 
tissue for microscopic examination. In exfoliative endometritis a 
cast of the uterine cavity may be thrown off, and therefore the 
extrusion, in extra-uterine pregnancy, of the decidua in one piece, 
triangular in shape, is not proof positive of the existence of this 
disease, but may be classed as presumptive evidence. On the 
other hand, the cast-off decidua may be lost at an early date, 
perhaps without the patient's knowledge. A tubal tumor of a 
size corresponding to the length of time the supposed pregnancy 
has existed, a slightly enlarged uterus, a relaxed vagina with 
bluish discoloration, a vaginal discharge of blood and shreds of 
tissue, and pain caused by pulling the cervix forward with the 
finger in the vagina make the diagnosis of tubal pregnancy most 
probable. 

The symptoms of rupture have been considered under the 
heading of symptoms, page 347. They are characteristic. Sudden 
faintness and collapse, together with severe pain in the region of 
the pelvis in a woman who has gone over her period, make a prob- 
able diagnosis of rupture of an extra-uterine pregnancy. If the 
patient recovers quickly the probabilities are in favor of its being 
tubal abortion. If there are recurrent attacks and a hematocele 
can be made out — a boggy mass of indefinite outline — the diagno- 
sis of tubal abortion is undoubted. If the patient goes from bad to 
worse, and there are rigidity of the abdomen, increasing abdomi- 
nal pain, pallor, sighing respiration, subnormal temperature, and 
a thready pulse, the diagnosis is tubal rupture and the abdomen 
should be opened at once. After the first attack of collapse and 
pain, there is to be felt a mass in the pelvis. 



350 



EXTRA-UTERINE PREGNANCY 



Late Extra- uterine Pregnancy 

In the later stages of extra-uterine pregnancy a correct diagnosis 
is seldom made until full term is reached. In the later months of 
pregnancy the diagnosis rests on finding the child lying outside 




Fig. 145. — Unruptured 



Ampullar Extra-uterine Pregnancy, 
(Williams.) 



Four Months. 



of the uterus, which is the size of a three months' pregnancy. The 
child can be palpated, the fetal heart sounds heard, and fetal 
movement felt, if the child is alive. The patient has had more 



DIFFERENTIAL DIAGNOSIS 351 

pain than is usual in normal pregnancy. The sound may be passed 
into the uterus to determine that it is empty. 

At full term the diagnosis is made by a history of false labor 
followed by a gradual , decrease in the size of the abdomen. The 
uterus is nearly normal in size and displaced by a large tumor 
either forward or backward. The child can be palpated and, if 
alive, the fetal heart sounds can be heard. The diagnosis at full 
term is easy to make, whereas previous to this time it is difficult. 

The diagnosis of combined intra- and extra-uterine pregnancy 
is seldom made previous to labor or operation. Sometimes in the 
case of twins when a child has been born from the uterus and there 
is delayed birth of a second child, examination leads to the diagnosis 
of extra-uterine fetation. Also, operation for ruptured extra- 
uterine pregnancy with abdominal hemorrhage may show the co- 
existence of uterine pregnancy. 



DIFFERENTIAL DIAGNOSIS OF EXTRA-UTERINE PREGNANCY 

Early Extra-Uterine Pregnancy before Rupture. — Here any enlarge- 
ment of tube or ovary not greater in size than a goose egg may 
be mistaken for an extra-uterine fetation. The presence of the 
symptoms and signs of early pregnancy (see Chapter XXII, page 
418) and the fact that an extra- uterine sac is more apt to be tender, 
are the only distinguishing features. 

Pregnancy in a retroverted uterus has been mistaken for extra- 
uterine pregnancy. A thorough examination, if necessary with 
an anesthetic, ought to remove all doubt. The symptoms which 
accompany retroversion of a gravid uterus should be borne in 
mind, viz., difficulty in micturition, retention of urine, pains in 
the pelvis, and constipation. If the bladder is overdistended it 
may be palpated. Passage of the catheter establishes the diag- 
nosis. Uterine fibroids have been mistaken for a gravid tube, 
though this is rare. Fibroids are seldom single and the uterus 
is apt to be distorted by their growth. 

Early Extra-Uterine Pregnancy after Rupture. — Symptoms and 
signs of early pregnancy with a paroxysm of severe abdominal 
pain, collapse, distention and rigidity of the abdomen, thready 
pulse and subnormal temperature, besides meaning ruptured 



352 EXTRA-UTERINE PREGNANCY 

i 

extra-uterine pregnancy, may indicate rupture of an ovarian cyst, 
or torsion of the pedicle of an ovarian cyst, rupture of a pyosalpinin 
or even of an appendiceal abscess, or rupture of a varicose vex, 
of the broad ligament. The treatment is the same in all of these 
conditions, immediate opening of the abdomen. 

If the rupture has been into the folds of the broad ligament 

there will be a mass of irregular 
outline at the side of the uterus, of 
doughy consistency. It is to be 
differentiated from a pelvic inflam- 
matory mass by its lack of hard- 
ness, by the absence of the history 
of infection, and by the absence of 
the signs of infection in vagina and 
cervix. 

In the event of symptoms of acute 
rupture in conditions simulating 
extra-uterine pregnancy the history 
of the case will throw light on the 
diagnosis. In the case of an ovarian 
tumor the history will show the pre- 
vious existence of a tumor, except 
in the case of a small one, and the 
uterus is not enlarged; in the case 
of pyosalpinx there is a history of 
genital infection and the tempera- 
ture is apt to be elevated, also the 
symptoms of hemorrhage, — weak 
heart, pallor, sighing respiration, 
and syncope, — are absent. In the 
case of rupture of an appendiceal 
abscess, the same is true and in 
addition there is a history of di- 
gestive disturbances, constipation 
and, usually, previous attacks of 
chronic rupture, those in which the 
prolonged, uterine abortion is one 
be mistaken for extra-uterine preg- 
at all that the case is one of uterine 



. 


v 


A 

;' \ 

\ 

\ 








* 


4 

:1 


I 








XL 


J 


*■ .-."A 9 




s' 


y 



Fig. 146. — Median Section of 
the Uterus of a Case of Isthmial 
Tubal Pregnancy of about Two 
Months, Showing the Decidual 
Modification of the Endometrium. 
(Couvelaire.) 

alternating with diarrhoea, 
right-sided pain. In cases of 
symptoms are not severe and 
of the conditions most apt to 
nancy. If there is any doubt 



DIFFERENTIAL DIAGNOSIS 353 

abortion, ether should be given and a thorough bimanual exami- 
nation made. The uterine hemorrhage in cases of extra-uterine 
pregnancy is generally of less amount than in cases of abortion 
and the clots are less frequently passed. The pain of rupture is 
a severe, agonizing sensation, one that can not be endured; in 
the beginning it is unilateral. The pain of abortion is that of 
labor, beginning as an aching, drawing pain in the lumbar region 
radiating toward the hypogastrium. 

The changes in the size and consistency of the uterus are more 
marked in uterine than in extra-uterine pregnancy. In the case 
of acute pyosalpinx or an exacerbation of a chronic pyosalpinx 
there are no softening of the cervix and no pain when the cervix 
is moved forward as in the case of extra-uterine pregnancy. In 
the case of rupture of varicose veins of the broad ligament, a rare 
event, there is nothing to point toward a diagnosis unless the 
patient has been under observation previous to the rupture. 

According to Baumgarten and Poffer (Wiener klinische Wochen- 
schrift, 1906, No. 12) acetonuria is present in extra-uterine preg- 
nancy. They examined the urine of one hundred patients and 
were able, by detecting acetonuria, to distinguish between extra- 
uterine pregnancy and other pelvic tumors. 

Late Extra-uterine Pregnancy. — If the walls of a pregnant uterus 
are abnormally thin, and the walls of the mother's abdomen are 
also thin, the fetus may be so plainly felt that a uterine may be 
mistaken for an extra-uterine fetation. Careful bimanual pal- 
pation will determine that the fetus is in the uterus. So, also, a 
sacculated pregnant uterus may simulate extra-uterine pregnancy, 
as well as pregnancy in a bicorned uterus. In the latter case an 
ether examination may serve to differentiate. 

A late extra-uterine pregnancy with an excess of hydramnios 
may simulate ovarian cyst. If the fetus can be outlined by pal- 
pation, or the fetal heart heard, the diagnosis is easy. 

The consideration of pregnancy in abnormal uteri, such as 
bicorned and rudimentary , will be found in the chapter on preg- 
nancy, page 432. 



23 



CHAPTER XX 

THE DIAGNOSIS OF DISEASES OF THE VAGINA 

Anatomy, p. 354: Vaginal discharge, p. 355. Age changes, 356. 

Malformations of the vagina, p. 356: Congenital malformations, p. 356. 
Acquired stenosis and atresia of the vagina, p. 359. 

Inflammations, p. 361 : Acute vaginitis, p. 362. Chronic vaginitis, p. 
363. Condylomatous vaginitis, p. 363. Emphysematous vaginitis, p. 364. 
Mycotic vaginitis, p. 364. Ulcerative vaginitis, p. 364. Senile vaginitis, p. 
365. Tuberculous vaginitis, p. 365. Syphilitic vaginitis, p. 365. 

Displacements of the vagina, p. 366: Cystocele, p. 366. Rectocele, p. 
369. Hernia or enterocele, p. 371. 

Injuries of the vagina, p. 371 : Lacerations of the perineum and pelvic 
floor, p. 371. Other injuries, p. 372. 

Foreign bodies in the vagina, p. 377. Gas in the vagina, p. 378. 

Vaginismus, p. 378. 

New growths of the vagina, p. 379. 

Fistulse of the vagina, p. 384. 



ANATOMY 

The vagina is a slit in the pelvic floor extending from the hymen 
to the cervix uteri and lying between the bladder in front and 
the rectum behind. It is nearly parallel to the plane of the brim 
of the true pelvis, and, with the patient in the upright posture, 
makes an angle with the horizon of about 60°. When seen in a 
median longitudinal section the slit of the vagina shows an S curve, 
the height of the first anterior protuberance of the S being at the 
summit of the perineal body. (See Figs. 6, p. 44 and 85, p. 219). 
In horizontal section in its middle course it is seen as an H-shaped 
opening. (See Fig. 151, p. 374.) Like the cavity of the uterus it is 
funnel-shaped, being larger above and smaller below, and it has two 
walls, an anterior and a posterior, which are in apposition unless 
the vagina is distended. 

The anterior wall extends from the hymen below, to the cervix 
above, the anterior fornix being the space formed between the intra- 
vaginal portion of the cervix and the upper portion of the anterior 

354 



ANATOMY 355 

wall. The length of the anterior wall is from two to two and a half 
inches (5 to 6 centimeters). In its lower portion it is closely 
united with the urethra, but higher up is surrounded by loose 
areolar tissue. 

The posterior wall extends from the hymen to the cervix uteri. 
It is three inches (7.5 centimeters) long or nearly an inch longer 
than the anterior wall. The space between the vaginal portion 
of the cervix and the upper part of the posterior wall is called 
the 'posterior fornix. It is deeper than the anterior fornix. 

The mucous membrane of the vagina is arranged in transverse 
folds or rugae. In the lower part of the centre of each wall is a 
single or double longitudinal thickening about seven-eighths inch 
long, known as the column of the vagina. The anterior column is 
the larger. 

The vagina is made up of three coats, the mucous membrane, 
the muscular coat, and the erectile tissue lying between the two. 
The arrangement of the mucous membrane in folds has been 
described. The epithelium covering the surface of the mucous mem- 
brane is of the squamous variety. There are no functioning glands, 
although the presence of gland tissue in the mucous membrane 
has been proved by von Herff and R. Meyer. The muscular coat 
consists of two layers, an external longitudinal, the stronger, and 
an internal, weaker, circular layer. The loose connective tissue 
uniting the mucous membrane with the muscular coat contains a 
plexus of veins which are arranged similarly to the veins in other 
erectile tissues. Because of its opening near the anus and the 
urethra, and its being invaded by the penis, the vagina is especially 
subject to infection from outside. Bacteria may be brought to it 
from the uterus and trauma may come from childbearing. 

Vaginal Discharge. — Although under normal conditions posses- 
sing no functioning glands and therefore no secretion proper, the 
surface of the vagina is covered by cast off epithelial cells and 
also bacteria with moisture having an acid reaction. This has a 
white creamy color and is not enough in amount to attract the 
woman's attention. The acidity of the fluid may be due to the 
lactic acid bacterium of Doderlein, though authorities are not 
agreed on this point. Be that as it may, pathogenic bacteria, unless 
especially virulent, do not live long in a healthy vagina, not finding 
a good culture medium or being killed by the microorganisms 



356 DISEASES OF THE VAGINA 

already there. Under pathological conditions an excess of alkaline 
secretion from a cervical catarrh may neutralize the acidity of the 
vagina and render it alkaline, thus furnishing an opportunity for 
the growth of disease-producing germs. 

Age Changes. — In the child the vagina is narrow and there are 
many rugae. Its walls are in close apposition. In the adult 
nulliparous married woman the vagina is more capacious, the 
widening being more in the upper than in the lower portion. 
After childbearing the vagina loses some of its folds, is larger, and 
may show alterations in shape because of its attachments being 
stripped from the cervix, or from laceration of the perineum. 

With the onset of the menopause atrophic changes begin. The 
mucous membrane loses its rugae and becomes smooth, and the 
vagina becomes contracted. In its upper portion the fornices are 
obliterated because of atrophy of the cervix and shrinking of the 
vaginal walls. 

MALFORMATIONS OF THE VAGINA 

Malformations of the vagina are congenital or acquired. As the 
vagina as well as the uterus is derived from the coalescence of 
Miiller's ducts it partakes of the congenital malformations of the 
uterus. 

Congenital Malformations. — These are : absence of the vagina, 
atresia of the vagina, septate vagina, double vagina, and per- 
sistence of a Miiller's duct, also the persistence of Gartner's duct. 

Absence of the Vagina. — This is not a very uncommon malfor- 
mation, instances of it appearing constantly in the periodical 
literature. It is associated with a greater or less degree of lack 
of development of the uterus, the uterus being represented gen- 
erally by a small knob of tissue. The ovaries and tubes may or 
may not be present. If the ovaries are present the patient, other- 
wise perfectly formed as regards figure, external genitals, breasts, 
and hair, suffers from painful menstrual molimina, and an oper- 
at ion for the removal of the ovaries may be necessary. The anomaly 
occurs without assignable cause in well-nourished women in other 
respects fully developed. 

The diagnosis is established by noting the absence of the introitus 
vaginae and by the bimanual recto-abdominal touch practised 



MALFORMATIONS OF THE VAGINA 357 

with the patient under the influence of an anesthetic. Something 
is learned also by palpation through the rectum with a sound 
placed in the urethra and bladder. As a rule no vestige of the 
vagina can be found in these cases. The entire absence of the 
ovaries can not be determined surely without an abdominal section, 
but failure to find them in a case where all the conditions for 
examination are favorable, i.e., lax and thin abdominal walls, 
together with the absence of menstrual molimina, makes the 
diagnosis reasonably certain. 

Atresia of the Vagina (Congenital). — Vaginal atresia is due to 
the fact that the Miiller's ducts fail to coalesce properly throughout 
their entire course, and the lower end of the vagina may fail to 
reach the hymen. As a rule there is some portion of the unoccluded 
vagina just under the cervix. In cases of congenital atresia of the 
vagina the vagina has been foimd dilated with secretion so that it 
bulged beyond the vulva, and has been known to cause retention of 
urine in the new-born because of pressure on the urethra. 

Occlusion of the vagina is to be differentiated from imperforate 
hymen, the latter, being developed from the margins of the urogeni- 
tal sinus, is not a complete obstructive membrane. It is likely 
that when the hymen is closed the closure is the result of adhesive 
inflammation. The hymen can generally be recognized as a 
separate structure below the introitus vaginae. 

Any defect of the vagina that causes retention of the uterine 
secretions should be diagnosed at birth or soon after. 

In the case of double uterus and vagina one vagina may appear 
as a blind sac running beside the well-formed vagina. It is thought 
now that most cases of atresia of the vagina owe their origin to 
inflammatory processes, perhaps during intra-uterine life, although 
there are cases, mainly those associated with uterine abnormalities, 
that are due to failure of development pure and simple. 

The diagnosis is generally made by chance or by the occurrence 
of hematocolpos or hematometra due to retained secretions in 
the vagina or uterus. 

Septate vagina and double vagina occur when the septum between 
the Mullerian ducts is partially or not at all absorbed. The partial 
form is more often observed, although all forms are rare. The 
septum may be placed diagonally so that it has the appearance 
of a transverse septum, thus partially occluding one side of the 



358 



DISEASES OF THE VAGINA 



vagina; it may extend a part of the length of the vagina, more 
often in the lower part, making two canals below and one above, 
or it may be only a ridge on the anterior or posterior wall of the 
vagina. If one Miiller's duct persists in the upper part of the 




Fig. 147. — Double Uterus and Double Vagina. (Kelly.) 

wall of a well-developed vagina and is connected above with a 
rudimentary supernumerary uterus while having no opening 
below j it may become dilated by retained secretions and appear 
as a cyst. Freund and others have reported such cases. 






MALFORMATIONS OF THE VAGINA 359 

Several cases of double vagina have been reported, notably one 
of double vagina and double uterus reported by H. A. Kelly 
("Operative Gynecology/' 2nd edition, page 210.) (See Fig. 147.) 

Gartner's duct, which in the embryo extends as a small canal 
through the side of the uterus or the broad ligament, the cervix, 
and the lateral or anterior wall of the vagina nearly to the introitus 
vaginae, may persist in the wall of the adult vagina. This may, 
rarely, give rise to cysts or even to an abscess. 

Retention of secretions due to atresia of the vagina, hemato- 
colpos, will be considered under acquired stenosis and atresia in 
the section on inflammations. 

The diagnosis of malformations is made by inspection and by 
digital examination. A small speculum is necessary and sometimes 
a Kelly cystoscope serves well for a view of an undeveloped 
vagina. Bimanual recto-abdominal touch will determine the 
condition of the uterus and ovaries. 

Acquired Stenosis and Atresia of the Vagina. — Stenosis of the 
vagina is a constriction or narrowing of the canal, while atresia is a 
complete closure or obliteration of it. 

J. Veit ("Handbuch der Gynakologie," Bd. Ill, 1908) thinks 
that most of the forms of vaginal atresia that cause retention of 
secretions as seen in the adult (hematocolpos) are to be classed 
as acquired, and assigns adhesive inflammation in the first years 
of life as a cause. This inflammation is not as a rule severe and 
has no symptoms often. We know of the frequency of gonorrheal 
vulvo- vaginitis in little girls, and also that inflammatory affections 
of the vagina are found in septicemia, scarlet fever, and diphtheria. 
Also, bacteria find ready entrance to the vagina in typhoid fever, 
dysentery, and similar affections. Taken in connection with the 
frequency with which traces of inflammatory action — for example, 
adhesions of the prepuce to the clitoris — are found in adults upon 
careful search, there seems to be ample ground for the theory that 
this sort of atresia originates in adhesive inflammation. 

In adults the cause of cicatricial stenosis is inflammatory action 
involving the submucous and muscular layers, due to injuries 
following childbirth, to caustic applications to the vagina, to 
improperly performed operations on the vagina, to foreign bodies 
left in the vagina, such as neglected pessaries, and to vaginitis 
phlegmonosa disseccans. As a result there arc found in the vagina 



360 DISEASES OF THE VAGINA 

crescentic folds, ring-like narrowings, transverse septa with minute 
openings, all being forms of stenosis, or there is a general shutting 
up of the entire canal, atresia. This atresia may be caused by a 
thin membrane, by a broad cicatrix several centimeters thick, 
or by the entire destruction of the vagina. 

Atresia or stenosis results in difficulty in coitus and in labor. 
In the congenital form of atresia of the genital organs there is 
apt to be diminished desire for sexual intercourse, especially if 
the ovaries are undevelopd. Another result of atresia is hemato- 
colpos, or accumulation of menstrual blood and uterine secretions 
in the vagina. These cases are generally first seen in girls who 
have passed the age of puberty without the appearance of the 
menstrual flow. They may experience pain in the abdomen. 
Examination shows a tumor behind the pubes that increases in 
size at each menstrual period and diminishes in the interval. 
On inspection of the vulva there is to be noted a bulging outward 
in the region of the introitus vaginae of an elastic tumor. The 
hymen is to be distinguished as a separate membrane. If the 
septum of the vagina is thin the dark color of the retained blood 
may manifest itself through the membrane. The bimanual recto- 
abdominal touch determines the presence of a fluctuating tumor 
in the situation of the vagina. 

If the accumulation of blood and uterine secretions has dilated 
the uterus, hematometra, it may be possible, with the aid of an 
anesthetic, to palpate the enlarged uterus. Dilatation of the 
Fallopian tubes from the same cause, hematosalpinx, sometimes 
results. In the latter event there may be an escape of fluid through 
the ostium abdominale of the tube into the peritoneal cavity with 
resulting peritonitis and symptoms of a severe grade. The danger 
of causing such extrusion of fluid should be borne in mind in making 
the bimanual touch and the amoimt of force used should be carefully 
limited. (See Chapter XXI, p. 398). 

Diagnosis. — The diagnosis of stenosis and atresia of the vagina 
offers few difficulties. The examining finger detects folds and 
ridges and partial narrowings, also double vagina, if present. A 
small speculum is generally indicated, for with it the physician 
gets a better view of an abnormally narrowed vagina. An open 
canal with an elastic tumor by its side makes probable a dilated 
rudimentary vagina. Cyst of the vagina must be excluded, how- 



INFLAMMATIONS OF THE VAGINA 361 

ever, and this can be done by determining the normal state of 
the uterus, tubes, and ovaries, as rudimentary vagina is seldom 
found with the other uterine organs perfectly normal. In all 
cases it is important to investigate the uterus and tubes. 

Differential Diagnosis. — Acquired stenosis and atresia must be 
differentiated from the congenital malformations, from vulvitis 
with atresia, and from vaginismus. The congenital malforma- 
tions are of relatively rare occurrence and are associated with 
other defects of development in uterus, tubes, or ovaries, their 
salient characteristics having been referred to. In adhesive vul- 
vitis there are apt to be traces of inflammatory action (adhesions) 
about the clitoris and nymphse, as well as at the introitus vaginae. 
There may be a history of gonorrhea, in this case look for cicatri- 
zation or redness in the neighborhood of the vulvo- vaginal glands ; 
or there may be a history of diabetes. Vaginismus is characterized 
by painful and spasmodic contractions of the muscles of the pelvic 
floor, especially those about the lower vagina. In cases of doubt 
the administration of an anesthetic will relieve all spasm. 



INFLAMMATIONS OF THE VAGINA 

(Vaginitis or Colpitis) 

Infection of the vagina depends on the number and vitality 
of the pathogenic bacteria that have found their way into it ; also 
on the state of health of the epithelium of the mucosa of the vagina. 
Any direct injury of the epithelium, or change in its character due 
to a uterine catarrh favors the development of infective organisms, 
and their entrance into the tissues. Just what bacteria are present 
as causative agents in any given case it is not always easy to 
determine; those that are most often found are the streptococcus, 
the staphylococcus, the colon bacillus, the tubercle bacillus, the 
gonococcus, and a gas- producing bacillus. 

Vaginitis is relatively more common in children than in adults, 
probably because of the softer epithelium in childhood. In children 
vulvo- vaginitis of gonorrheal origin is not uncommon, and vagi- 
nitis is a frequent concomitant of the acute infectious diseases. 
In adults vaginitis is a rare disease. 

Etiology. — The following may be mentioned as predisposing 



362 DISEASES OF THE VAGINA 

and exciting causes of vaginitis: Retained discharges from an 
insufficient opening in the hymen; irritation from excessive 
venery or masturbation ; congestion from pregnancy or abdominal 
tumor, or organic disease of the heart, liver, or kidneys; gaping 
of the vulvo- vaginal orifice; douches of irritating substances, 
such as strong corrosive sublimate; foreign bodies, such as pes- 
saries and tampons; oxyuris vermicularis ; injuries received at 
labor and abortion, and recto- and vesico- vaginal fistulse. 

Acute Vaginitis 

Pathology. — In the mild cases it is characterized by a reddened, 
swollen, granular mucosa which is bathed in an abundant thin 
purulent discharge. The entire vagina is usually involved. In 
the severe cases, swelling and hyperemia increase and excoriations 
and even necrosis may occur. In puerperal conditions and in the 
acute infectious diseases the mucosa may be covered with a whitish- 
gray or greenish deposit or by a false membrane made up of the 
necrosed upper portion of the mucosa — pseudo-diphtheritic vaginitis. 
Cases of true diphtheritic inflammation, due to the Klebs-Loefner 
bacillus, have been described, though they are rare. 

In certain extremely severe cases the inflammatory process 
extends to the tissues about the vagina and there is a paravaginitis. 
This is the case in an erysipelatous vaginitis similar to the erysipelas 
of the skin, a rare disease, and in paravaginitis phlegmonosa dis- 
secans, which sometimes accompanies typhoid fever. In the 
phlegmonous variety the whole or the greater part of the tube of 
the vagina is cast off as a slough with subsequent stenosis. 

Symptoms. — Burning pain referred to the vulva, a profuse 
leucorrheal discharge, generally purulent in character and irritating 
to the vulva, smarting on urination if the vulva is involved and 
also if urethritis is present, as in the gonorrheal form, a sense of 
fullness in the pelvis, and backache, are the usual symptoms. 
Vulvitis goes with vaginitis in many cases, especially in children. 
The constitutional symptoms are not marked, the temperature 
seldom going above 101° F., except in the streptococcic, diphthe- 
ritic, and paravaginitic forms. 

Diagnosis.— The patient is placed in the Sims position and the 
labia are separated. The character and amount of discharge are 



INFLAMMATIONS OF THE VAGINA 363 

noted and a finger placed in the vagina finds that it is hot. In 
the gonorrheal variety, which is relatively rare and is secondary to 
infection of Bartholin's glands, the urethra, and cervical canal, 
the discharge is generally of a greenish-yellow color. The smallest 
Sims speculum that will serve is used because the vagina is very 
sensitive. The mucous membrane shows some of the many char- 
acteristics described under the pathology of acute vaginitis. If 
the vaginal discharge originates from the uterus or an abscess 
discharging into the vagina instead of from the vagina itself, the 
speculum examination will settle this point. 

Chronic Vaginitis 

Pathology. — Chronic vaginitis may succeed acute vaginitis, or, 
more often, may be of a chronic type from the beginning. It is 
apt to result from the irritation from pessaries or tampons, or 
other foreign bodies. In the gonorrheal form it is usually secondary 
to gonorrheal infection of the uterus, Bartholin's glands, or the 
canal of the cervix uteri. 

The disease is generally confined to certain portions of the 
vagina rather than to the entire surface, as it is in the acute form. 
The affected portions are reddened, often mottled with slight 
ecchymoses, or they are brown in color from old deposits of blood 
pigment. The surface is granular, or glazed and smooth and free 
from ruga?. Microscopically it is seen that the surface epithelium is 
somewhat thinner than normal, whereas the submucous tissue is 
thick, dense, and infiltrated with small round cells; sometimes 
blood pigment shows in deposits in places. In granular vaginitis 
the granulations on the surface are crescent-shaped, small in size, 
and pretty generally scattered over the surface of the vagina. 
Certain special varieties of chronic endometritis are observed. 

Gonorrheal vaginitis should be mentioned as a variety, although 
it has few characteristics that distinguish it from simple vaginitis. 
It is generally secondary to gonococcus infection elsewhere and 
the discharge is apt to be of a greenish color. 

Condylomatous Vaginitis. — Condylomata similar to those found 
about the vulva, but set not so close together, are to be found 
sometimes in vagina? that have been subject to long-continued 
irritations, as from gonorrheal endocervicitis. The condylomata 



364 DISEASES OF THE VAGINA 

may be scattered over a large or a small area in the vagina. They 
show under the microscope hyperplasia of the papillae accompanied 
by secondary epithelial proliferation. 

Emphysematous Vaginitis. — This variety occurs most often 
during pregnancy and occasionally during the puerperium, and 
is characterized by the presence in the vaginal walls of small cysts, 
generally not much larger than a pea, and containing gas. They 
may appear to be bluish in color due to the thinness of their walls. 
They are due to a gas-producing bacillus the exact nature of which 
has not been determined, and are developed in the connective- 
tissue spaces. Sometimes the cysts are as large as a filbert. On 
pressure with the finger the cyst disappears, and on opening it 
with a knife gas escapes. 

Mycotic Vaginitis. — This is a form of vaginitis in which there 
is a growth of a fungus in the vagina, the Oidium albicans. The 
walls of the vagina are covered with large numbers of grayish- 
brown, slightly elevated masses which are easily detachable. 
Beneath them the mucosa is swollen and eroded. Under the 
microscope the masses are seen to be made up of epithelial cells 
and the spores and mycelium of Oidium albicans. It has been 
thought that the dark color is due to blood-coloring matter. 

Ulcerative Vaginitis. — Ulcerative vaginitis is a term used to 
distinguish the form of the disease in which the mucosa has been 
destroyed by ulceration, as in the case of an ill-fitting pessary. 
Following the true form of ulceration in which the submucous tissue 
is involved a cicatrix results. 

An interesting case of ulcerative vaginitis in a case of bacillary 
dysentery has been reported by M. M. Canavan (Boston Med. and 
Surg. Jour., Nov. 11, 1909, page 705). In this case a woman fifty- 
one years old, an inmate of the Danvers State Hospital for the 
Insane for four years, was affected by bacillary dysentery during an 
epidemic of the disease in 1908. She died, just after a vaginal 
hemorrhage, on the fourteenth day of her illness. At the autopsy 
the following condition was found, to explain the hemorrhage and 
a bloody vaginal discharge which had been noted during the last 
six days of her illness. The surface of the vagina was dull brown- 
ish-gray in color and was covered with a tenacious pigmented exu- 
date and there were clusters of deep-notched winding ulcers at the 
fornices of the vagina. 



INFLAMMATIONS OF THE VAGINA 365 

Senile Vaginitis. — In senile vaginitis, a form of vaginitis peculiar 
to women who have passed the menopause, the mucous membrane 
is atrophic and therefore poorly nourished. The irritation of the 
vagina from a uterine discharge is apt to proceed to the stage of 
ulceration, generally many small scattered ulcers being present. 
These enlarge, coalesce, cause hemorrhage by the erosion of small 
vessels, and form scar tissue. There may be adhesions between 
the walls of the vagina. The disease is a common one in women 
over sixty years of age. 

Tuberculous Vaginitis. — This variety is practically always second- 
ary to tuberculosis elsewhere, although a problematical case of 
primary tuberculosis of the vagina has been reported by Carl 
Friedlander and Olshausen. The disease, not a common one, 
occurs in the form of one or more ulcerations, generally situated 
in the neighborhood of the cervix. The ulcers are flat, circum- 
scribed, with infiltrated hyperemic margins, the base covered 
with yellowish-gray material or studded with tubercles. Histo- 
logically the floor of the ulcer consists of granular, caseous material, 
beneath which the tissue is infiltrated with typical miliary tuber- 
cles or diffuse tuberculous tissue. The diagnosis is made by the 
microscope. 

Syphilitic vaginitis needs only to be mentioned. Chancres, 
ulcers, or gummata may be found in the vagina. They are rare 
and are diagnosed by the characteristic lesions of the disease in 
other parts of the body, by the history of syphilis, and by the de- 
tection of the spirochaeta pallida in the discharge. 

Symptoms. — The symptoms of chronic vaginitis are vaginal 
discharge, generally purulent in character, a sensation of fullness 
in the pelvis, perhaps itching of the vulva with smarting on urina- 
tion if the vulva also is affected. The general health may suffer 
as a result of the irritation and consequent loss of sleep, but there 
are no characteristic constitutional symptoms. Leucorrhea may be 
the only symptom. 

Diagnosis. — The patient is in the Sims position. A Sims specu- 
lum is employed. It is noted that the vagina is not sensitive as 
in the acute stage and does not feel hot to the examining finger. 
The mucous membrane is thickened and is of a dark red or bluish 
color; in places it is smooth and in others it is roughened and the 
discharge is thinner and less purulent than in the acute stage. 



366 DISEASES OF THE VAGINA 

It is to be remembered that the vagina may be simply a canal 
which conducts purulent or other fluids from the uterus or the 
surrounding organs to the vulva; therefore be sure that the 
inflammatory process is primary in the vagina. In the case of 
gonococcus infection, as pointed out already, the process is second- 
ary to infection in the urethra, Bartholin's glands, and the cervical 
canal; consequently those situations should receive attention. 

The special varieties of vaginitis just enumerated should be 
borne in mind and their characteristics recognized. Cultures 
and smears are made from the discharges and pieces of tissue 
removed for microscopic examination in all doubtful cases. 



DISPLACEMENTS OF THE VAGINA 

In this section we shall consider cystocele, rectocele, and the 
rare condition known as true hernia of the vagina. 

Cystocele 

Cystocele is a prolapse downward of the anterior wall of the 
vagina together with the base of the bladder. It would appear 
that in some cases the muscular wall of the vagina has given way 
and the bladder wall in the cystocele is covered only by vaginal 
mucosa. If the urethra alone is dislocated downward the con- 
dition is called urethrocele. In this case the urethra may be detected 
as a thickened ridge, and passage of the sound together with 
palpation shows the situation of the urethra. 

Etiology and Frequency. — The chief cause of cystocele is child- 
bearing, the anterior movable segment of the pelvic floor, that 
portion lying between the arch of the pubes and the uterus (see 
Chapter XIII, Etiology of Prolapse, page 223) being dislocated 
and stretched. Injuries of the perineum, actual tears of the 
anterior vaginal wall, and subinvolution of the vagina are con- 
tributory causes. Rupture of the perineum and consequent lack 
of support to the anterior wall of the vagina is an important 
factor in the causation. Cystocele is most often met with in 
working women who have less careful obstetric supervision than 
the women of (he upper classes, and get on their feet before involu- 



DISPLACEMENTS OF THE VAGINA 



367 



tion of the uterus, vagina, and perineum have been completed. 
As injuries of the perineum and pelvic floor are the chief cause 
of subinvolution it behooves the physician to diagnose and repair 
these injuries promptly and thus prevent the occurrence of cysto- 
cele, which may not develop for 
months or years after the re- 
ceipt of the injuries. 

Symptoms. — The symptoms 
depend on the extent of the 
prolapse. They are, a sensa- 
tion of fullness in the orifice of 
the vagina, and the feeling that 
something projects in that sit- 
uation on straining, the bulg- 
ing cystocele being mistaken 
for uterine prolapse ; also drag- 
ging and weight in the pelvis, 
in the case of large cystocele 
and prolapse, and inability to 
empty the bladder easily. If 
the urethra is dislocated 
(urethrocele) there is more or 
less incontinence on coughing, 
laughing, and straining. There may be residual urine in a dislo- 
cated bladder with consequent cystitis. This is rare. 

Diagnosis. — There may or may not be evidence of bulging of 
the anterior wall of the vagina when the introitus vaginae is 
inspected with the patient in the dorsal position. Straining brings 
the anterior wall into view, however. A curved sound introduced 
through the urethra shows the situation of the base of the bladder 
as determined by palpation of its tip under the anterior vaginal 
wall. The extent of the prolapse may be estimated by examining 
the patient in the standing position and asking her to strain while 
the examination is made. In the knee-chest position the cystocele 
disappears. In large cystoceles the vaginal wall is thickened and 
has the appearance of skin. In prolapse of the uterus it may be 
ulcerated. 

Differential Diagnosis. — We must distinguish cystocele from 
cyst or other tumor of the vagina, hypertrophy of the bladder 




Fig. 148.— Cystocele. 



368 



DISEASES OF THE VAGINA 



wall in chronic cystitis, sub-urethral abscess, and true intestinal 
hernia of the vagina. Tumor of the anterior vaginal wall does not 
increase in size or tension on straining and coughing, it does not 
disappear on pressure or on putting the patient in the knee-chest 
position, filling the bladder has no effect on the size or elasticity 
of the tumor, and palpation of a sound in the bladder shows that 
there is something besides the walls of the bladder and vagina 
between the tip of the sound and the examiner's finger in the 
vagina. 

Hypertrophy of the bladder wall in chronic cystitis to the extent 
of forming a tumor in the vagina is rare. The diagnosis of cystitis 
by means of the cystoscope and examination of the urine, together 




Fig. 148a. — Diagrammatic Representation of Cystocele. 

with the symptoms of cystitis, point the way toward a differentia- 
tion. Palpation of the greatly thickened bladder by the finger 
in the vagina will settle the diagnosis. 

Sub-urethral abscess is diagnosed by placing a sound in the 
urethra and palpating the tumor in the vagina on the soimd. 
In this way it will be plain that the urethra is not involved in the 
tumor. Besides, there are present in the case of the abscess symp- 
toms and signs of inflammation, and there is apt to be a minute 
opening of the abscess into the urethra through which pus may 
be forced on pressure. 

Anterior intestinal vaginal hernia is a rare condition in which 



DISPLACEMENTS OF THE VAGINA 



369 



coils of small intestine occupy a sac formed by a pouch of pro- 
lapsed peritoneum between the front of the uterus and the bladder. 
This pouch projects under the anterior vaginal wall in the same 
situation as a cystocele. On pressure a true hernia disappears 
with a gurgling sound, it disappears when the patient is in the 
knee-chest position, it is soft and doughy to the touch, and the 
coils of intestine may be palpated between a sound in the bladder 
and a finger in the vagina, thus showing a greater thickness of 
the intervening structures than in the case of cystocele. 



Rectocele 

Rectocele is a forward protrusion of the anterior rectal wall 
into the vagina, although the name is given to any bulging of the 
posterior vaginal wall, whether the protrusion contains the rectum 
or not. It is possible for the posterior vagina to become separated 
from the rectal wall, because 
of the loose connection of the 
two structures. As a rule the 
rectal wall is in the dislocated 
vagina. Rectocele is one of 
the concomitants of complete 
uterine prolapse. 

Etiology and Frequency. — 
Rectocele is caused by rupture 
of the perineum and pelvic 
floor, by consequent subinvo- 
lution of the vagina, and by 
chronic overclistention of the 
rectum by feces and scybalous 
masses. 

The firm support ordinarily 

given to the anterior wall of 

the rectum during defecation, 

due to contraction of the levator ani muscle at this time, is lacking 

because of the injury of this muscle. Therefore the fecal mass 

covered by rectal and vaginal walls is pushed forward into the 

vagina. Constant straining accentuates the faulty condition. 

Like cystocele, the development of a rectocele is a matter of 
24 




Fig. 149. — Rectocele. 



370 



DISEASES OF THE VAGINA 



months and years, and the disease is frequent among the working- 
classes for the same reason as in the case of cystocele. 

Symptoms. — The symptoms are a sense of fullness in, or pro- 
trusion from, the vulva, weight and dragging in the pelvis, and 
difficulty in defecation. Sometimes the woman is obliged to 
replace the rectocele with her fingers before she can empty the 
bowel, and in pronounced cases of rectocele there is apt to be 
rectal tenesmus and a feeling as if the rectum had not been emptied 
completely. 

Diagnosis. — Bulging of the posterior vaginal wall may be visible 




Fig. 149a. — Diagrammatic Representation of Rectocele. 



on separating the labia when the patient is in the dorsal position. 
Straining brings the wall into view and it recedes again when the 
effort is over. The physician, passing a forefinger through the 
anus, hooks it forward into the rectocele. This makes positive 
the diagnosis and differentiates separation of the posterior vaginal 
wall from the rectum, from cases of true rectocele. We must 
rule out cysts and other tumors of the posterior vaginal wall and 
true posterior vaginal hernia or enterocele. Both of these are 
palpated between a finger in the rectum and another finger in the 
vagina. A cyst or tumor is fluctuating or hard, and is felt as a 
distinct mass between the two fingers, whereas in rectocele the 
rectum and vaginal walls alone are between the fingers. 



INJURIES OF THE VAGINA 371 

In the case of enterocele the doughy feel of intestine with gur- 
gling on pressure is to be made out, and, on placing the patient 
in the knee-chest position the tumor disappears. 

Hernia or Enterocele 

True hernia or the descent of a loop of intestine in a pouch of 
peritoneum either into the recto-vaginal cellular tissue below 
Douglas' cul-de-sac, or into the cellular tissue between the uterus 
and the bladder, is a rare occurrence. It is sufficient to note that 
cases have been reported and that the diagnosis is made by pal- 
pating the tumor ^and eliciting the doughy feel characteristic of 
intestine, by noting gurgling noises in the tumor when it is pressed 
upon, and by Observing that the tumor increases in size on straining, 
but disappears when the patient is placed in the knee-chest position. 
Such tumors must be differentiated carefully from rectocele, 
cystocele, or tumor of the vaginal wall. (See these sections.) 

In very rare cases an enterocele has been known to find its 
way to the vulva. In this situation it must be distinguished from 
inguinal hernia that has reached the labium majus. Examination 
of the external abdominal ring will show whether the ring is free. 
Also it is to be differentiated from a cyst of Bartholin's gland or 
other tumor of the labium. In the case of the enterocele it has an 
origin from above, has an impulse on coughing, and disappears 
with the patient in the knee-chest position. A tumor of the labium 
has none of these characteristics. 



INJURIES OF THE VAGINA 

Injuries of the vagina may be due to (1) childbearing, to too 
rapid expulsion of the head, breech, or shoulders, or to pressure 
of the blades of forceps, (2) to coitus, where there is disproportion 
between the size of the penis and the vagina, and too great violence 
is used, (3) to unskillful instrumentation, and (4) to a fall on a 
sharp body such as a picket. 

(i) Childbearing. — A majority of injuries due to childbearing 
consist of lacerations of the perineum, next in frequency are 
lacerations of the upper vagina, due to the extension of a tear of 
the cervix to the vagina. Sometimes a circular laceration in the 



372 DISEASES OF THE VAGINA 

upper vagina may separate the cervix partially or wholly from 
the vagina. Generally the tears of the vagina are longitudinal in 
direction. On one occasion I repaired immediately after a version 
an extensive longitudinal laceration of the anterior vaginal wall 
not involving the cervix. Lacerations of the vagina are more apt 
to occur where the vaginal wall has been narrowed by cicatrices 
or its elasticity has been impaired by disease. 

Lacarations of the Perineum and Pelvic Floor. — By this term is 
meant not only injuries of the perineal body so-called, — really not 
an anatomical entity, — but also damage to the structures compos- 
ing the pelvic floor. These are the levatores ani, — sphincter vaginae, 
sphincter ani, and transversus perinei muscles, and the following 
fasciae: posterior layers of the triangular ligament, — called also 
the transverse perineal septum, a strong mass of connective tissue 
and elastic tissue in which the muscles are inserted, the anal fascia, 
the recto-vesical fascia, and the deep superficial fascia. 

By conjoined recto- vaginal examination of a nullipara one 
determines that the tissues between the fingers are of the shape 
roughly of a triangle, with its slightly convex base the space on the 
skin between the anus and the fourchette, and its apex at the 
upper limit in the vagina of the lower anterior curve of the S 
formed by that canal in its course to the cervix. The tissues feel 
firm and elastic (the transverse perineal septum) and there is a 
distinct convexity upward (the patient being in the dorsal position) 
of the lower posterior vaginal wall. 

An attempt to evert the rectum through the opening of the 
vagina will encounter much resistance and cause pain to the 
patient. If, now, the patient is asked to strain it is noted that 
the anterior and posterior walls of the vagina already in contact 
are pressed more firmly together and that the perineum, — the skin 
surface between the vagina and rectum, — bulges outward, and 
the distance between anus and fourchette is increased. If, on 
the contrary, the woman is told to draw in the muscles it will be 
found that the anus and the skin perineum are lifted inward 
and upward toward the posterior surface of the arch of the 
pubes. 

By vaginal palpation pressure directed backward and on both 
sides of the middle line encounters definite elastic resistance (the 
levator ani muscles). If the patient is asked to contract the mus- 



INJURIES OF THE VAGINA 



373 



cles they are felt to become rigid. The significance of a laceration 
depends on the number of structures involved and on the extent 
of the injury. 

In most first labors there is some injury of the fourchette in the 
median line. These superficial tears are of little practical impor- 
tance because they do not involve the supporting structures of 
the pelvic floor. If the structures composing the perineum are 




/i«r e 



V^ a 



Fig. 150. — Diagrammatic Longitudinal Median Section of the Pelvis, Showing 
Structures of the Pelvic Floor. (Dickinson.) 



rigid and non-elastic, as in the case of old primiparae, the tear is apt 
to be deeper and therefore of more serious import. 

Tears of the pelvic floor proper are of three sorts: (a) median, 
(b) lateral in one or both sulci, and (c) a combination of these 
two. 

(a) Median tears, if of any considerable depth, are apt to involve 
the sphincter ani muscle to a greater or less degree. To put the 
case a little differently, a vast majority of the lacerations of the 



374 



DISEASES OF THE VAGINA 



sphincter ani are median tears. In the case of complete laceration 
of the perineum the pelvic floor proper is not injured to the extent 
that its supporting power is lessened, therefore we do not expect 
to find the results of laceration of the pelvic floor in the form of 
cystocelc, retroversion, and prolapse. 

Partial or complete loss of control over the bowels is to be ex- 
pected after laceration of the sphincter ani. If only a portion of 
the fibers of the sphincter are injured the patient may be able to 
control her bowels if they are constipated, but not if they are loose ; 
or the retentive power over gas may be lost. 

Complete Laceration. — Suppose the laceration is complete. 
Inspection shows a gaping vulva with the retracted ends of the 




Fig. 151. — Complete Median Laceration of the Perineum, 
not Injured. (Gilliam.) 



Levator Ani Muscles 



sphincter ani muscle showing as a minute dimple on each side 
of the anus at the ends of the contracted, crescentic muscle. The 
recto- vaginal septum, when not extensively torn, stretches above 
as a tense band across the open anus, in which the bright red 
corrugated mucosa of the rectum is seen. Unless the levator ani 
has been injured, the walls of the upper vagina are in contact. 
If the laceration has not been complete a finger inserted into the 
anus estimates the amount of damage to the sphincter by noting 
the strength with which it grasps the finger. 

(6) and (c). Lateral tears in the sulci are the common forms 



INJURIES OF THE VAGINA 



375 



of injury to the pelvic floor. They are the important ones from 
the point of view of the dislocation and diseases of the pelvic 
organs which result if they are not repaired. 

The lateral tears injure the levator ani muscle. After the injury 
the muscle ends contract and carry with them the torn fascia?; 
some of the injured structures are replaced by connective tissue, 
and, in the case of tears reaching the surface, by cicatricial tissue. 
In the course of many years there may be marked atrophy of all 
the structures composing the pelvic floor. The exact kind of 
deformity that results in any given case is determined by the 







B:" 








jtf~ 


m -'■&■ 




Pk i 










W Rectum " IE 


i . 




>: ' ; -^ 


■ -:\ 








r~\ 





Fig. 152. — Perineum Lacerated in Both Sulci. Levator Ani Muscles Injured. 

(Gilliam.) 



structures involved and the time which has elapsed since the 
receipt of the injury. Sundering the transverse perineal septum 
permits the transversus perinei muscles to contract and draw 
the edges of a wound to both sides of the vulva. At an exami- 
nation of a fresh tear in the hours following delivery it is possible 
to get a fairly accurate idea of the structures involved, although 
the swelling and distortion of the tissues at this time render the 
determination not easy. By separating the labia and sponging 



376 DISEASES OF THE VAGINA 

off the blood, the difference between the shining vaginal mucosa 
and the oozing raw tissue becomes apparent. The anterior vaginal 
wall should be held up against the pubes and the tears traced to 
their farthest limits. With a finger in the rectum the upper por- 
tions may be brought better into view. A good light and the 
patient on a table or on an ironing board on the edge of the bed 
are essentials to an exact diagnosis. After an interval of months 
and years we can not say exactly what has occurred at the time 
of injury. Dissection on the living, in the course of an operation 
undertaken for the purpose of repair, will not give us this informa- 
tion because of the abundant blood supply of the parts involved. 
Inspection of an old laceration in the sulcus shows a gaping vulva, 
vaginal walls apart, perhaps cystocele, rectocele, or prolapse, the 
perineum is flat and longer than normal because the rectum is 
displaced backward. When the patient strains the vaginal walls 
roll down instead of holding closer together, and the perineum 
between the fourchette and anus, instead of bulging, is con- 
cave. Palpation shows a groove in the sulcus and a lack of hard- 
ness here when the patient contracts the muscles of the pelvic 
floor. The perineal septum is always more or less injured in 
these cases, and palpation of the perineum with one finger in the 
vagina and the other in the rectum will make manifest that the 
convex summit of the perineal body, the top of the anterior S 
curve of the lower vagina, has disappeared and in its place is a 
depression. In many cases very little injury is apparent when the 
vulva is inspected because the skin has not been severed. The 
physician should be on the lookout for the "skin perineum" and 
not be deceived by it. By hooking a finger into the vagina the 
absence of the firm convex surface of the perineum will be appar- 
ent at once. A common form of laceration is a tear in one sulcus 
together with a tear in the median line. 

By the former we assume that the levator ani is injured and by 
the latter the transverse perineal septum. Often both sulci are 
affected and there is also a tear in the median line below. Too 
much can not be said of the importance of making an exact diag- 
nosis of the situation of the tear in every case of rupture of the 
pelvic floor, for in this way only can repair be intelligently carried 
out. 

(2) Injuries due to coitus are not frequent. Sometimes the first 



FOREIGN BODIES IN THE VAGINA 377 

coitus causes a laceration of the hymen which extends to the vagina 
and there may be serious hemorrhage. Rape has caused severe 
and fatal injury of the vagina in children and also in women. In 
willing coitus whenever there is a large penis and a small vagina 
injury may occur if force is used. 

(3) Injuries due to unskillful instrumentation are not very un- 
common. The violence is done sometimes by the patient intro- 
ducing sharp instruments into the vagina in an effort to produce 
abortion, and at others by the ignorant abortionist, also the un- 
skillful use of the obstetric forceps or other instruments may cause 
laceration, often of serious import. 

(4) Falls on sharp bodies, such as the picket of a fence or the 
handle of a pitchfork, have produced extensive and even fatal in- 
juries. 

Hematoma of the vagina is a rare condition. It occurs both as a 
result of trauma and following labor, the latter being by far the 
more frequent cause. There is a collection of blood just under the 
mucous membrane and the tumor is dark in color and fluctuates. 



FOREIGN BODIES IN THE VAGINA 

Little girls may introduce foreign bodies in the vagina, just as in 
the other accessible cavities of the body, from a spirit of inquisi- 
tiveness. Thus pebbles, seeds, fruit-stones, pencils, hairpins, and 
other objects have been removed from the vaginae of little girls. 
Older girls and women, especially the sexually perverted, have 
introduced the ends of candles, pencils, and other things for pur- 
poses of masturbation. Spools, rubber balls, sponges, pieces of 
cotton, and many other substances have been taken from vaginae in 
which they had been placed in the hope of preventing conception. 

The vagina has served as a repository for smuggled and stolen 
property, such as jewelry, gems, and banknotes, and, in the case of 
the feeble-minded, a legion of strange articles have been secreted 
there. The foreign body most often found in the vagina is a neg- 
lected or forgotten pessary. As is well known, a hard-rubber 
pessary becomes incrusted with lime salts as soon as its polish is 
gone. The roughened surface chafes the mucous membrane until it 
ulcerates. Soft-rubber pessaries irritate the vagina more than the 



378 DISEASES OF THE VAGINA 

hard-rubber variety, as a rule, but not being so firm do not cut so 
far into the tissues. Pessaries have been retained for a long series 
of years in reported cases, and sometimes with resulting stenosis of 
the vagina. Sometimes a vesico-vaginal or a recto- vaginal fistula 
is caused in this way. Pin worms and round worms may inhabit 
the vagina. There is a foul discharge from the vagina if ulceration 
is present. The diagnosis of a foreign body is an easy matter when 
digital and speculum examination are made, attention having been 
attracted by the vaginal discharge. 

Gas in the Vagina (Garrulity of the Vagina.) — An accumulation of 
gas in the vagina that is expelled with a noise on straining or moving 
the body quickly from one position to another is a not very rare 
condition. Every gynecologist of experience has seen many cases. 
In the past it has been thought that such a condition was due ex- 
clusively to injuries to the pelvic floor, so that in certain positions 
of the body, as on the side, air entered, to be expelled later when 
the woman assumed the upright position. Although such a cause 
may be operative in some cases, the recent investigations of Klein- 
wachter, Taussig, and Veit ("Handbuch cler Gynakologie," zweite 
AufL, Bd. Ill, page 201) go to prove that the accumulation of gas 
in the vagina, a condition most often found in the puerperium, is 
due to a gas-forming bacterium. The disease is thought to be allied 
to vaginitis emphysematosa (see page 364) and has been classed by 
Veit as among the inflammations of the vagina. 

When the disease is due to injury of the pelvic floor with subin- 
volution coupled with weakening of the abdominal walls, the diag- 
nosis is not so difficult. If these conditions do not obtain, and it is 
due to a gas-forming organism, drying the vagina and packing it 
with dry tampons on which boric acid powder has been dusted 
will kill the organism and thus confirm the diagnosis. We must 
rule out recto-vaginal fistula) in these cases, for gas in the vagina 
may come from the rectum. 

VAGINISMUS 

Vaginismus may be regarded as a symptom rather than a disease. 
It consists of a hyperesthetic condition of the orifice of the vagina 
and is characterized by spasmodic and painful contractions of the 
levator ani and constrictor vagina} muscles. Sometimes the irri- 



NEW GROWTHS OF THE VAGINA 379 

tability extends to the muscles of the thighs or other sets of muscles 
in the neighborhood of the vulva. 

Vaginismus is a rare condition found, as a rule, in young, neurotic 
women and in the newly married. It may occur, however, in 
women who have borne children. It may be dependent on a local 
lesion, such as urethral caruncle or inflammation of the vulva. 
Masturbation, by overstimulation of the sexual organs, causes 
vaginismus in some instances. Ineffectual attempts at coitus pro- 
duce in time erosions at the introitus and nervous excitability and 
dread of pain. A large penis and a small vagina may cause tonic 
spasms of the muscles of the pelvic floor. Cases are on record where 
the penis has become imprisoned in the vagina by vaginismus so 
that it was necessary to administer an anesthetic to the woman 
before the couple could be separated. The vagina may be very 
sensitive, so that the slightest touch or even taking a douche causes 
contraction of the muscles, and a vaginal examination is impossible 
without an anesthetic, or it may be caused only by violent inter- 
course. The nervous system suffers when vaginismus has existed 
for any length of time and various nervous stigmata may be 
present. A vaginal examination will determine the cause of the 
condition. If necessary a second examination with an anesthetic 
must be made. Vaginismus is one of the causes of dyspareunia, — 
painful coitus. (See Chapter X., page 146.) 



NEW GROWTHS OF THE VAGINA 

The new growths of the vagina are: (1) cysts, (2) myomata, (3) 
sarcomata, (4) carcinomata. 

(i) Cysts. — Cysts of the vagina are the most frequent of the 
tumors found in this organ. As a rule, they are between the size of 
a pea and an English walnut, are single, and found on the anterior 
rather than on the posterior wall. Very large cysts may develop 
in exceptional instances, and in such cases the cyst develops in the 
broad ligament; very rarely a series of cysts is found. A cyst of 
the vagina appears as a bluish-white, rounded eminence in the 
pink mucous membrane of the vagina. It is elastic to the feel. If 
the cyst is situated superficially it projects more into the lumen of 
the vagina and is of a darker color because of its thin walls ; if it 



380 



DISEASES OF THE VAGINA 



is situated deep in the vaginal wall it projects less prominently and 
is not so dark in color. 

Cysts of the vagina are due to (a) inclusions of epithelial tissue 
during operations for the repair of lacerations of the perineum, 
or during spontaneous healing of such injuries; (b) vaginal gland 

tissue, and (c) the remains of embryonic 
structures, such as Gartner's and Mid- 
ler's ducts. The inclusion cysts are 
generally found in the neighborhood of 
the perineum, in the posterior wall, low 
down. These are small, spherical in 
shape, have as contents mucus made 
turbid by desquamated epithelium, and 
are lined with a layer of stratified 
squamous epithelium. Not much is 
known about the cysts which arise 
from vaginal gland tissue. They are 
infrequent as compared with the other 
two varieties, however. Cysts originat- 
ing in persistent Gartner's ducts are 
comparatively frequent, and are situ- 
ated in the lateral or anterior walls of 
the vagina. These cysts are more apt 
to be cylindrical in shape than per- 
fectly globular, corresponding in their long axis to the axis of the 
duct, are filled with a clear straw-colored fluid, and are lined 
with cylindrical epithelium. 

A persistent Miiller's duct has been referred to in the chapter 
on anomalies. A blind end of a misplaced ureter has been known 
to form a cyst of the vagina. 

The diagnosis offers little difficulty. Cystocele, urethrocele, and 
rectocele must be ruled out, also other tumors of the vagina. An 
arjerio-venous aneurism has been mistaken for a cyst of the vagina, 
also vaginal hernia, or collection of blood in a double vagina. A 
sound in the urethra or bladder will assist in excluding urethrocele 
and cystocele, and a finger in the rectum, rectocele. 

A cystocele or rectocele should increase in density on straining, 
whereas a cyst does not. A vaginal hernia should transmit an 
impulse on coughing and has a characteristic doughy feel. It dis- 




Fig. 153. — Inclusion Cyst 
of Vagina Occurring Three 
Years after Repair of a Peri- 
neal Tear. (Cullen.) 



NEW GROWTHS OF THE VAGINA 



381 



appears when the patient is placed in the knee-chest position. An 
aneurism should have a thrill. The characteristics of double vagina 
have been described in the section on anomalies. 

Echinococcus cysts of the vagina are very rare and are generally 
due to echinococcus colonies in the 
mesometrium burrowing in the 
recto- vaginal septum. 

(2) Myomata. — Myomata or fi- 
broids of the vagina are rare. 
Some seventy authentic cases have 
been reported in the literature, being 
found in most cases in women be- 
tween forty and fifty years of age. 
They occur as small, spherical, hard, 
nodular tumors, seldom over two 
inches in diameter, projecting from 
the vaginal wall into its lumen. 
They are usually single, but may be 
multiple and are not associated with 
fibroids of the uterus, although a 
case where both existed in the same 
patient has been reported by Fabri- 
cius (Zentralblatt fur Gyndkologie, 
1908, No. 36, 1191) and another by 
Kelly and Cullen ("Myomata of the 
Uterus,' ' page 440). The tumor is sessile and has a fibrous 
capsule of its own separating it from the surrounding tissues. 

The etiology of these tumors, just as in the case of fibroids of the 
uterus, is unknown. They are apt to be the seat of edematous 
degeneration. 

The diagnosis is generally easy, the fluctuating character of a 
vaginal cyst serving to distinguish it from a myoma, and in the 
case of sarcoma and carcinoma the mucous membrane covering 
the tumor is involved, whereas in myoma it is not. The hard 
character of the tumor serves to distinguish it from cystocele, rec- 
tocele, or hernia. 

(3) Sarcomata. — Sarcoma of the vagina is of two sorts, (a) 
sarcoma of the vagina in children, and (b) sarcoma of the vagina 
in adults. 




Fig. 154. — Cyst of Anterior 
Vaginal Wall Probably Due to 
Occlusion of Gartner's Duct. 
(Cullen.) 



382 DISEASES OF THE VAGINA 

(a) Sarcoma oj the vagina in children is of doubtful etiology, but 
has been observed very soon after birth. It generally develops in 
the first year of life and is fatal within a year or two. In one case 
reported the child lived to be six years old. About forty cases of 
this disease are on record. The disease is characterized by the 
development of vesicle-like polypi of a dark red (hemorrhagic) and 
pinkish-gray (translucent) color, arranged in racemose clusters. 
In the beginning of the disease the first appearance is a polyp, usually 
attached to the anterior wall of the vagina. In five out of the six- 
teen of the twenty-six cases analyzed by Starfinger ("Sarcom der 
Vagina bei Kindern," 1900) however, the disease began on the 
posterior wall. Its surface is smooth and it resembles a mucous 
polyp of the uterus. From this polyp there develop in the course of 
time, weeks or months or even years, proliferations of cystic polypi 
until they fill the vagina and project through the vulva. The disease 
is apt to involve the bladder at an early date, then the cervix and 
uterus, and finally the peritoneum. Metastases are infrequent, the 
growth extending mostly by continuity and generally forward into 
the bladder and peritoneum and not backward into the rectum. 
Histologically the growth consists of round and spindle-shaped 
cells, also giant cells and striped muscle fibers. The diagnosis 
before the disease has progressed extensively is very difficult. A 
vaginal discharge in an infant should lead to a speculum exami- 
nation, a Kelly cystoscope with a reflected light being the best 
instrument for this purpose. 

(b) Sarcoma of the Vagina in Adults. — Fifty-two cases of this 
disease are on record. It is a disease of later adult life, few of the 
cases being under forty years of age. Here, as in the case of the 
child, the disease begins as a polyp most commonly, although 
instances of its starting as a diffuse infiltration are reported. It 
appears to lie latent for a considerable time, just as with the child. 
The primary lesion may be on either wall of the vagina, and it 
progresses in its development as a ring-like infiltration so that the 
vagina is narrowed, or it grows as a diffuse tumor of one wall. 
Ulceration occurs. The disease does not often penetrate the vesico- 
vaginal or recto-vaginal septa or extend largely, but metastases 
to other organs are formed relatively early. Histologically the 
tumor is made up of small round cells, spindle cells, and giant cells, 
but not striped muscle fibers. Melanotic sarcoma has been report- 



NEW GROWTHS OF THE VAGINA 383 

ed in three cases. The appearance of a polyp situated on the 
vaginal wall, usually with a broad base and of firm consistency, 
should excite a suspicion of sarcoma. Microscopic examination 
of the removed polyp will distinguish sarcoma from myoma or 
carcinoma. 

(4) Carcinoma of the Vagina. — Carcinoma of the vagina is sec- 
ondary to cancer of the uterus, in which event it is relatively com- 
mon, or it is primary, when it is comparatively rare. Schwarz 
observed 84 cases of primary cancer of the vagina among 35,807 
gynecological patients, or something over two-tenths of one per 
cent. It forms about one per cent of all carcinomata of the gen- 
erative organs. Primary cancer of the vagina is a disease of advanced 
life, but may occur as early as the twenty-sixth year; it occurs only 
in women who have borne children and is more often found in the 
posterior wall. When seen early it is a nodule an inch or an inch 
and a half in diameter. The edges are sharply defined, infiltrated, 
and injected. The surface soon becomes necrotic and ulcerated 
and may exhibit papillary elevations. The nodule is firmly em- 
bedded in the surrounding tissues after the very earliest stages. 
The disease extends extremely rapidly both superficially and deeply, 
and if the lower portion of the vagina is infected the inguinal lymph 
glands are involved. The disease tends to extend to the rectum 
more often than to the bladder and it may reach to the vulva; it 
originates in the squamous epithelium and has all the character- 
istics of squamous-celled cancer (see Cancer of the Uterus, page 267). 

In getting a specimen of tissue for microscopic examination the 
deeper tissues must be excised because the superficial portions 
consist usually of inflammatory products only. The symptoms 
in the early stages are bleeding from the vagina, on coitus espe- 
cially, also a watery vaginal discharge. 

In making the diagnosis we must rule out secondary carcinoma 
of the vagina. This is done by discovering cancer of the cervix, 
cervical canal, or fundus uteri, or cancer of the rectum or bladder. 
Carcinoma in these situations must be rigidly excluded before pro- 
nouncing the disease primary in the vagina. Myoma is excluded 
by the physical appearances of myoma and by the microscope. If 
a primary cancerous area lies behind a stenosis of the vagina the 
diagnosis is more difficult. Inflammations of the vagina with ul- 
cerations are differentiated by the absence of infiltration under the 



384 DISEASES OF THE VAGINA 

abcess. If an ulceration caused by an ill-fitting or neglected pessary 
does not heal rapidly a portion should be excised for microscopic 
examination. 

There have been reported a case or two of 'primary chorioepitlie- 
lioma of the vagina, and venereal warts in conjunction with condy- 
lomata of the vulva occasionally occur. 



FISTULA OF THE VAGINA 

An opening between the vagina and the surrounding hollow 
viscera is called a fistula. Of such fistulae there are five sorts: — ■ 
(1) Vesicovaginal, (2) Urethrovaginal, (3) Uretero-vaginal, (4) 
Recto-vaginal, and (5) Entero-vaginal. The last is extremely 
rare. For the sake of completeness we must mention a communi- 
cation between the vagina and a pelvic abscess, or the peritoneal 
cavity, openings made, as in the case of (5), fistula into the in- 
testine, in the course of operations. 

Vaginal fistulae are caused by sloughing of the vaginal walls 
due to prolonged pressure of the child's head during labor, by 
injuries from obstetric instruments, by ulceration due to pessaries 
and other foreign bodies, or by ulcerations from foreign bodies in 
the bladder. They result also in the late stages of carcinoma of 
the cervix, vagina, rectum, and bladder, and following operations, 
especially hysterectomy. In the last case and also when a vesico- 
vaginal fistula has been formed by operation, nature closes the 
opening, generally in a short time. 

Vesicovaginal fistula is the most frequent of all the forms of 
vaginal fistula?, although not nearly so often met with as in the 
olden days before the art of obstetrics had been perfected to its 
present high degree of excellence. The vaginal and bladder walls 
are involved in varying extent. Almost the entire base of the 
bladder may slough away, leaving the orifices of the ureters exposed 
in the edge of the fistula, or the opening between the bladder and 
vagina may be no larger than a pin's point. The symptoms are 
leakage of urine from the vagina, and, unless great care is main- 
tained by the patient to keep dry, excoriation, redness, and sore- 
ness of the vulva, perineum, and thighs. The amount of urine lost 
will depend on the size of the opening and on the retentive power 



FISTULA OF THE VAGINA 



385 



of the vagina. Sometimes urine is retained in the vagina while the 
patient is recumbent, the pelvic floor being uninjured and the in- 
troitus small. Often when the fistula is small the patient may void 
a portion of the urine through the urethra and the rest will escape 
through the vagina. 

The diagnosis is made by the history of incontinence and by the 
physical examination. The digital touch, if the fistula is large, will 




Fig. 155. — Scheme of the Different Sorts of Genital Fistulae, not Including 
Fistula-in-Ano. (Gilliam.) 1. Urethrovaginal. 2. Vesico-vaginal. 3. Recto- 
vaginal. 4. Vesico-uterine. 5. Uretero-vaginal. 6. Entero-vaginal. 

indicate the size and situation of the fistula. The patient is placed 
in the Sims position and a Sims speculum introduced. Inspection 
shows the size, shape, and situation of the fistula. A sound or probe 
passed through the urethra may be made to appear through the 
opening in the vagina. In larger fistula) the bladder wall is apt to 
be much injected (cystitis) and often incrusted with lime salts. 

25 



386 DISEASES OF THE VAGINA 

These must be removed gently. Vesico- vaginal fistula gives a fine 
opportunity to inspect the bladder and to catheterize the ureters. If 
the fistula is very small and there is doubt as to its situation, the 
patient is placed in the dorsal position and the bladder is filled with 
milk and water. Examination of the cleansed vagina through a 
duckbill speculum will show the point at which the white milk 
leaks through the fistula. 

Uretero-vaginal fistula is detected in the same manner. The 
bladder is filled with milk and water and it is noted that clear urine 
and no milk collects in the vagina; measure the bladder urine and 
that which gathers in the vagina, and, if the two kidneys are secret- 
ing an equal amount, it is possible, by finding that the two quan- 
tities are the same, to decide that all the urine from one ureter 
escapes into the vagina. The sense of smell is a great help in de- 
tecting the presence of urine, for in some instances the differentia- 
tion of watery fluid coming out of the uterus or the peritoneal cavity 
from urine is not easy. To aid in distinguishing urine in cases of 
vaginal fistula it is sometimes of use to give the patient five drops 
of doubly distilled turpentine on a lump of sugar three times a 
day. It imparts the characteristic odor of violets to the urine. 
Methylene blue, one to two grains every four hours given by the 
mouth, renders the urine a bluish-green color. The colored urine 
may be seen to escape from a fistula. 

Urethro- vaginal fistula is a rare variety of fistula due to syphilitic 
or malignant ulceration or operation on the urethra. The opening 
between the urethra and vagina is generally small and is situated 
in the upper course of the urethra. There is no incontinence of 
urine unless the fistula involves the neck of the bladder. The 
diagnosis is made by passing a probe into the urethra and through 
the fistula. For fistulse involving the bladder and ureters see also 
Chapters XXIV and XXV, pages 474 and 492. 

Recto-vaginal fistula results in the late stages of cancer of the 
cervix and also in the case of neglected pessaries and imperfect 
union of a lacerated perineum. Rarely this fistula results from 
syphilitic or tuberculous lesion of the vagina. The opening is 
generally small in size. 

The symptoms arc the escape of flatus, and also more or less fluid 
feces, into the vagina. Vaginitis and vulvitis are apt to result from 
the irritation caused by the fecal matter. 



FISTULA OF THE VAGINA 387 

The diagnosis is founded on the history, and on the examination. 
The patient is placed in the dorsal position and the anterior vaginal 
wall raised by a Sims speculum. If the fistula can not be seen a 
probe is passed in the most likely spots and if it enters an opening 
which connects with the rectum its point may be felt by a finger in 
that organ. Also, one may inject the rectum with milk and water 
and note its escape into the vagina. 

Entero- vaginal fistula is rare. It results generally from a surgical 
operation. The presence of feces in the vagina, the exclusion of an 
opening into the rectum by means of inspection of the rectum 
through a proctoscope, the character of the fecal matter (chyme), 
and finding the opening of the fistula in the upper vagina on in- 
spection and probing with the patient in Sims position, will establish 
the diagnosis. For fistula-in-ano see Chapter XXVI, page 516. 



CHAPTER XXI 

THE DIAGNOSIS OF DISEASES OF THE VULVA 

Anatomy, p. 388 : Age changes, p. 391. 

Congenital Anomalies, p. 391: Malformations of the vulva as a whole, 
p. 391. Development of the external genital organs, p. 392. Anomalies, 
p. 393. Malformations of the clitoris, p. 393. Malformations of the 
labia majora, p. 394. Malformations of the labia minora, p. 394. Mal- 
formations of the hymen, p. 396. Imperforate hymen, p. 396. Hermaph- 
roditism, p. 399. 

Injuries of the vulva, p. 400. 

Inflammation of the vulva, p. 402: Simple or catarrhal vulvitis, p. 402. 
Gonorrheal vulvitis, p. 402. Diabetic vulvitis, p. 403. Thrush, p. 403. 
Elephantiasis, p. 404. Pruritus vulvae, p. 404. Kraurosis vulvae, p. 404. 
Edema and gangrene, p. 405. Varix, p. 405. 

Venereal lesions of the vulva, p. 406; Chancroids, p. 406. Chancre, 
p. 406. Mucous patches, p. 407. Condylomata, p. 407. Gumma, p. 408. 

Tuberculosis of the vulva, p. 408. 

Cysts of Bartholin's gland, p. 408; Abscess of Bartholin's gland, p. 409; 
Differential diagnosis of cyst and abscess, p. 412. 

Labial Hernia, p. 412. 

Benign tumors of the vulva, p. 413. 

Malignant tumors of the vulva, p. 414: Cancer, p. 414; Differential 
diagnosis of cancer, p. 415. Sarcoma, p. 416. 



ANATOMY 

The term vulva is applied collectively to the structures often 
called the external genital organs, and includes: the mons veneris, 
the labia majora and minora, the clitoris, the vestibule, and the 
hymen. 

The Mons Veneris. — The mons veneris is the eminence in front of 
the symphysis pubis. It is formed by a collection of subcutaneous 
fat and is covered with coarse hair, generally of the same color as 
the hair of the head. The upper limit of the hair is a horizontal 
line, differing from the male pubic hair, which is continued up- 
ward along the linea alba in a V shape. Below, the hair is con- 
tinuous with the hair on the outer surfaces of the labia majora. 

The Labia Majora.— These are two thick, parallel folds of skin 

388 



ANATOMY 389 

extending from the mons veneris nearly to the anus. They are 
wider above and grow thinner as they approach the perineum 
where they are lost. Each fold is called a labium ma jus and the 
opening where the two meet in the middle line is called the pu- 
dendal slit (rima puclendi). The posterior limit of the slit is a 
transverse cutaneous fold called the fourchette, the depression 
between this and the base of the hymen being the fossa navicularis. 




f 




Fig. 156. — Diagram of the Vulva. (Dickinson.) 

The labia majora are pigmented more than the surrounding skin 
and the outer surfaces contain sebaceous glands and are covered 
with more or less hair, the hair becoming scanty and short to- 
ward the posterior parts. The inner surfaces of the labia majora 
are smooth, and the thin skin covering them resembles mucous 
membrane in the virgin, but is harder in the parous woman. The 
outer ends of the round ligaments become lost in the upper por- 



390 DISEASES OF THE VULVA 

tions of the labia majora, which are made up of fat and connec- 
tive tissue. 

The Labia Minora, or Nymphae. — These are two thin, pink, deli- 
cate folds of skin extending from the frenum of the clitoris above, 
downward to be lost on the inner surfaces of the labia majora at 
about the level of the opening of the vagina. They are developed 
from the margins of the genital cleft. They have no hairs but 
abundant sebaceous glands. Each fold is a labium minus, and 
the two labia may be asymmetrical. In the virgin the lesser labia 
are entirely covered by the greater labia, but under abnormal 
conditions the nymphae may project beyond the labia majora, 
and in this case they are pigmented. 

The Clitoris. — This is a rudimentary penis developed from the 
genital eminence, but it is without a urethra traversing it (see Fig. 
157). It is situated between the labia majora and is concealed by 
the upper portions of these structures, it is about an inch and a 
quarter long, and arises from the pubic arch by two crura, which 
unite to form the body of the clitoris. At its tip is a glans, which is 
covered partially or wholly by a prepuce, that, coming from above 
and partially encircling the glans, is prolonged downward into the 
labia minora. The clitoris is made up of erectile tissue and the 
glans is covered by a very sensitive epithelium. At the base of the 
glans are sebaceous glands which secrete smegma. 

The Vestibule. — The space between the clitoris above, the en- 
trance of the vagina below, and the nymphae on the sides is the 
vestibule. It is developed from the urogenital sinus, is, roughly, 
triangular in shape, and is pierced in its centre by the external 
orifice of the urethra, (meatus urinarius) which presents a longi- 
tudinal slit closed by two little lips (labia urethras) which form a 
slight elevation above the surface of the vestibule. 

The Hymen. — This is a thin, circular, white or light pink, per- 
forated membrane which separates the vulva from the vagina. 
It is made up of connective tissue and elastic fibers and is covered 
on both sides with stratified epithelium. Its shape, thickness, 
and even its situation vary in different cases. The opening into 
the vagina (introitus vaginae) is generally in the anterior part; 
it may be ring-shaped (annular), admitting the tip of the forefinger; 
this is the commonest condition, or it may be cribriform, fimbriate, 
horseshoe-shaped, septate or linear. The tissues of the hymen 



CONGENITAL ANOMALIES 391 

may be tough and resistant, though generally friable and torn with 
the first coitus or even by vaginal examination, always by parturi- 
tion. The remains of the torn hymen are called carunculae myrti- 
formes. In the infant and embryo the hymen projects forward 
into the cleft between the labia in the form of two apposed longi- 
tudinal lips. (See Figs. 163 to 170.) 

The Glands of Bartholin. — These glands furnish a clear, glairy, lu- 
bricating mucus for coitus and for the delivery of the child during 
labor. They are two in number, each is about the size of a large 
pea and is situated at the side of the posterior part of the vaginal 
canal in the sphincter vaginae muscle. The opening of the canal 
of the gland is a minute pin-point hole to be found in the posterior 
portion of the inner surface of the labium majus. In women who 
have borne children it is just outside the last and uppermost car- 
uncula myrtiformis. 

Age Changes 

Infancy. — In infancy there is no visible hair on the mons, and 
the labia majora are rounded and firm, the labia minora projecting 
between them as slightly elevated, pink folds. (See Fig. 203.) 

Puberty. — At puberty hair grows on the mons and the outer 
surfaces of the labia majora, the latter becoming pigmented and 
increasing in size so that they conceal the nymphse. The nymphse 
may grow larger after puberty, and if they do, the exposed parts 
become pigmented and of coarser texture. Enlargement of the 
nymphse has been ascribed to masturbation, and it is likely that 
such is sometimes the case, though this is not the only cause. 

Old Age. — The hair on the mons and labia majora becomes 
gray and is shed soon after the hair of the head. After the meno- 
pause the mons loses its fat gradually and the labia shrink so that 
in old age the orifice of the vulva gapes. The hymen if unbroken 
shrinks, and the introitus vaginae is narrowed in any event. 



CONGENITAL ANOMALIES 

Malforations of the Vulva as a Whole. — True congenital anom- 
alies of the vulva, such as complete atresia of the vulva, arc very 
rare and occur for the most part in non-viable fetuses. There are 



392 



DISEASES OF THE VULVA 



on record, however, one case of double vulva in an adult, and many 
cases of infantile vulva where the labia majora and minora were 
small and flat, the introitus narrow, and the mons veneris not 
prominent and poorly provided with hair. Such a condition is 
usually associated with poorly developed general physique. Pre- 
cocious development of the vulva is found sometimes in conjunction 
with precocious menstruation in very young children. In these 
cases the breasts also show abnormal development. In the chapter 
on diseases of the vagina, page 356, I have referred to the not in- 
frequent occurrence of a normal vulva and normal body form 



Ghns cVttonciis*.^ 




llrogpmtal 
Sinus. 



Anus 



Fig. 157. — The External Genital Organs at the Beginning of the Third Month 
of Fetal Life. (After Keibel.) 



associated with a rudimentary uterus and vagina. An apprecia- 
tion of the steps in the development of the several parts of the 
urogenital system is a necessity for the proper understanding of 
the different congenital malformations of the external genitals. 

Development of the External Genital Organs. — At the end of the 
first month of intra-uterine existence there is developed in the 
outer surface of the caudal region of the embryo a depression in the 
skin (Fig. 158), which grows deeper until it reaches the allantois 
and rectum to form the cloaca (Fig. 159). About this time ap- 
pears the genital eminence above the cloaca, flanked on each side 
by a fold of skin. The genital eminence in the female becomes 
later the clitoris, and the folds of skin the labia majora, the nymphse 
being developed on their inner surfaces. (See Fig. 157.) Figure 






COXGEXITAL ANOMALIES 393 

160 shows the differentiation of the bladder and rectum from 
the allantois and hind gut respectively, and the beginning of the 
formation of the perineum by the downward extension of the 
perineal septum between the rectum and the urogenital sinus, 
which has been formed by a union of the ducts of Miiller and the 
cloaca. The proctodeum, the posterior portion of the invagination 
of the skin that is to form the anus, is now differentiated. In 
Fig. 161 the urethra has been formed and a septum divides the 
urinary from the genital tract. Figure 162 (at about the end of 
the fourth month) shows the vagina, although not yet with a canal, 
developed from the ducts of Miiller and separated by the hymen 
from the vulva. The perineum has its mature shape and the anus 
now opens backward. The vestibule, the clitoris, and both sets of 
labia are already formed, although they do not assume their final 
shape until the fifth or sixth month. The external genital organs 
are at birth much more completely developed than the internal 
organs, which remain in a more or less rudimentary condition until 
the child is eight or ten years old. 

Anomalies. — Persistence of the Urogenital Sinus. — This is most 
often met with as an opening of the anus into the vagina, "anus 
vaginalis" so called, in which there is incontinence of feces because 
of the absence of the sphincter ani muscle. There is met with rarely 
a hypospadias, or a connection of the urethra with the vagina high 
up, the vestibular canal being long. Another form of hypospadias, 
also rare, is the condition where there is no urethra and the bladder 
opens directly into the vestibular canal. In these cases there is of 
necessity incontinence of urine and the bladder opening can be 
seen in the anterior wall of the vagina. 

Occasionally a case of persistent cloaca is met with, the perineal 
septum and the sphincter ani not being developed. Incontinence 
of feces exists in such cases. 

Malformations of the Clitoris. — The clitoris may be absent, it may 
be small, it may be hypertrophied, it may be cleft, as in epispadias, 
or the prepuce may be adherent. Absence of the clitoris is an 
extremely rare occurrence, and so is cleavage of the clitoris, but 
the organ is found very small not infrequently, and large quite com- 
monly. Sometimes the clitoris attains the size of a small puerile 
penis. Such a condition has no clinical significance and requires no 
treatment unless it interferes with coitus, — an unusual happening. 



394 DISEASES OF THE VULVA 

An adherent prepuce, on the other hand, may be the source of 
sexual irritation and conduce to masturbation, and in children 
may be the cause of enuresis, some writers even attributing the 
existence of symptoms of grave derangement of the general ner- 
vous system to this as a cause. All women who apply for gyne- 
cological treatment should be examined with reference to the 
adhesions of the prepuce. The prepuce should be pushed upward 
with two fingers until the glans can be distinguished. By the use 
of gentle pressure, aided if necessary by the flat end of a surgical 
probe, the prepuce may be separated from the glans. Hard, white 
specks of retained smegma not larger than a pin's point are gen- 
erally found under the adherent prepuce. Some authors maintain 
that adhesion is a condition normal to the prepuce in both sexes. 
The number that are found to be adherent in girls and women, if 
every case coming under observation is examined for this con- 
dition, has been surprisingly large in my experience, and my own 
view is that adhesion of the prepuce in the girl and woman plays 
a much less important role in the causation of symptoms than in 
the boy and man. 

Malformations of the Labia Majora. — The following malformations 
have been described, although all must be regarded as extremely 
rare. Absence of the labia, rudimentary labia, multiple labia, 
hypertrophy of the labia, and adhesions of the labia. The only 
ones that require comment are multiple and adherent labia. The 
former consists of longitudinal division of the labia into several 
folds of skin instead of one, and the latter is a part of apparent 
vulvar atresia. If the closure is complete the child is non-viable. 
Generally there is a small opening anteriorly through which mic- 
turition takes place. 

Malformations of the Labia Minora. — The same malformations 
as in the case of the labia majora have been met with. The two 
that need description are hypertrophy of the labia and adherent 
labia. Hypertrophy of the nymphce is by no means rare. It reaches 
a stage of extreme development in the " Hottentot apron," so- 
called, in which the labia extend downward some seven or eight 
inches between the thighs. This condition is unknown among the 
women of civilized races. A moderate degree of hypertrophy is 
not uncommon and is of no importance unless it interferes with 
coitus. Adherent labia represent inflammatory affections during 







Depresstoq 
m shin 

Fig. 158. — The Allantois, the 
Hind gut, M filler's Duct and the 
Depression in the Skin. 




Cloaca. 



Fig. 159. — The Depression in 
the Skin Has United with the Al- 
lantois and Hindgut to Form the 
Cloaca. 




'UroaeniTal 
-* Smu$ 

Fig. 160.— The Bladder Is 
Formed, also the Beginning of the 
Urethra and the Vagina, Both 
Opening into the Urogenital Sinus. 
The Rectum opens Separately 
into the Proctodeum. 



Anus 



Fig. 161. — The Urethra is 
further Developed, the Opening 
of the Vagina Reaches nearer the 
Vulva, and the Perineum Is 
Formed. 




Vestibule: 



Perineum 



Fig. 162. — Complete Development. The Urogenital Sinus Has Be- 
come the Vestibule. The Hymen nearly Closes the Opening of the Vagina, 
which Has Become Enlarged. The Rectum is more Capacious and the 
Anus Opens Backward Posterior to the fully Developed Perineum. 



Figs. 158-162. — Five Diagrams of Longitudinal Median Sections op 
Embryos, Illustrating the Stages of Development of the Genital 
Organs. (After Schroeder.) 395 






396 DISEASES OF THE VULVA 

fetal or infantile life. The union is generally incomplete and 
there is an opening through which urine can escape. Imme- 
diate division of the two labia is demanded if there is no open- 
ing when a child with this deformity is born, otherwise it is 
non-viable. 

Malformations of the Hymen. — Authorities are divided as to the 
structures from which the hymen is developed. Pozzi's view of 
its development ("Traite de Gynecologie," quat. edit'n, p. 1383) 
seems as near the facts as any. It is that the hymen is developed 
in the fifth month from both the vagina above, after fusion of 
the Mullerian ducts, and from the vestibular canal, — a vestige 
of the urogenital sinus, — below. Gellhorn (Amer. Jour. Obstet., 
Aug., 1904, p. 145), who has studied this question most carefully, 
thinks that the indications point to the hymen being derived from 
the Mullerian ducts exclusively. 

The hymen has never been found absent by competent observers. 
As has been stated in describing the anatomy, the form of the hy- 
men varies much in different individuals, also its thickness. Of 
the different forms in which the hymen is found, the fimbriate or, 
denticulate, the septate, the cribriform, the annular, the linear and 
the crescent, the annular and crescent-shaped hymens are the most 
common. The hymen may be so tough and resistant that it is not 
ruptured by attempts at sexual intercourse, on the other hand it 
may be so dilatable that it stretches to accommodate the penis with- 
out tearing. The rule is that it is generally torn by intercourse, and 
always by parturition. Cysts and solid tumors of the hymen have 
been described, but they are excessively rare. 

Imperforate Hymen. — The opening in the hymen may be ex- 
tremely minute and yet pregnancy may ensue. A case has been 
recorded by H. L. Horton (Boston Med. and Surg. Jour., vol. 82, 
p. 33) of a patient who was in labor with a hymeneal opening 
measuring only one-sixteenth of an inch in diameter. From the 
most recent researches the view has gained ground that imper- 
forate hymen is a misnomer, the condition being one really of 
atresia of the vagina, for in many of the cases recorded after the 
liberation of retained menses a hymen has been found outside the 
obstructing membrane. In other words, the lower end of the va- 
gina, which is a solid structure in the early stages of development 
after the fusion of Miiller's ducts and before the canal is formed, 







397 



398 



DISEASES OF THE VULVA 




remains impervious in the adult. Be the cause what it may, the 
result is a damming up of the uterine secretions with resulting 
hematocolpos, hematometra and even hematosalpinx. 
The vulva of every female infant should be inspected by the 
obstetrician and the patency of the orifice 
of the vagina determined by passing into 
it a catheter. Most cases of imperforate 
hymen are not discovered until puberty, 
in rare instances the malformation has not 
been suspected until early marriage. There 
may be few symptoms, and these nothing 
more than a sense of weight and fullness in 
the pelvis. As the accumulated blood in- 
creases in amount the patient may experi- 
ence colicky pains in the abdomen and in- 
terference with micturition and defecation. 
Amenorrhea, when the body shape and the 
psychic changes of puberty announce the 
presence of that state, should lead to a 
local examination, especially if there is 
a menstrual moli- 
men. 

Diagnosis of Im- 
perforate Hymen. — The diagnosis rests on 

the physical examination. Inspection 

shows a bulging in the region of the in- 

troitus vaginae which is of a bluish tinge. 

The urethral orifice is dilated. Recto- 
abdominal palpation reveals the presence 

of a fluctuating mass in the region of the 

vagina; if the case is an early one, the 

vagina alone may be dilated, if a later 

case the uterus, or the uterus and the 

tubes are enlarged (see Figs. 171, 172 and 

173.) The utmost gentleness should be 

employed and it is wise not to make too 

exact a diagnosis because of the danger of 

rupturing the tubes, should they be distended. A more precise 

finding is gained after an anesthetic has been administered, and 



Fig. 171. — Hemato- 
colpos, Caused by Atre- 
sia of the Vagina or 
Imperforate Hymen. 




Fig. 172. — Hematocolpos 
and Hematometra. 



CONGENITAL ANOMALIES 



399 



this ould not be given until the preparations have been made 
for evacuating the fluid.- 

Hermaphroditism. — Hermaphroditism (Hermes and Aphrodite), 
the union of the two sexes in one individual, is a term generally 
used to describe a person whose external genital organs partake of 
the characteristics of both sexes. Every embryo is in the begin- 
ning potentially both male and 
female ; some preponderating in- 
fluence determining the develop- 
ment of the Wolffian or the Miil- 
lerian ducts, so that it is not 
strange that remnants of the un- 
developed ducts should be found 
in the adult. The steps of the 
development of the sexual organs 
are indicated in Fig. 71, page 198 
and in Figs. 158-162. 

True Hermaphroditism. — A true 
hermaphrodite, according to 
Neugebauer, is an individual who 
can impregnate another and also 
can be impregnated itself by 
another individual; not only that, 
it may impregnate itself. Accord- 
ing to this definition true hermaphroditism occurs in the lower 
animals, as in the cestopods. The gastropods, on the other hand, 
can fructify each other but not themselves. True hermaphroditism 
in the functional sense does not occur in man, but in the sense that 
an individual may have a genital gland which contains both 
ovarian and testicular tissue, an ovotestis, five undoubted cases 
have been reported, by V. Salen, Garre, Pick, and Schickele. One 
of Pick's two cases was that of a woman who had borne several 
children and Garre's case was that of a male hermaphrodite twenty 
years old. Therefore, true hermaphroditism, defined as the occur- 
rence of a combination gland of both ovary and testicle in the same 
person, does occur. A preponderating number of the reported 
cases are instances of pseudohermaphroditism. Neugebauer in his 
exhaustive work has gathered together 1,886 cases of pseudoher- 
maphroditism in addition to the five cases of true hermaphroditism. 




Fig. 173. — Hematocolpos, Hemato- 
metra and Hematosalpinx. 



400 DISEASES OF THE VULVA 

Pseudohermaphroditism. — Pseudohermaphroditism is more often 
of the male variety. 

Male False Hermaphroditism. — Here the body form, stature, 
hair, and breasts are of the male type; testicles are always present, 
but the external genital organs are malformed. The penis is un- 
dersized and the glans imperforate, while the penile urethra is 
represented by a groove running into a cul-de-sac which corre- 
sponds to an incomplete vulva. The two halves of the scrotum 
have failed to unite in the median line, thus resembling the labia 
majora, and enclose a rudimentary vulvar orifice scarcely admit- 
ting a finger tip. One half of the scrotum may contain a testis, and 
the other testicle may be in the inguinal canal. It is a condition of 
hypospadias in the male. There are many varieties of this type. 
The cases are apt to be regarded as females and are brought up as 
girls until after puberty when they show sexual inclination toward 
females. 

Female False Hermaphroditism. — This is less common than the 
male kind. The ovaries are always present, but may be in the 
labia majora. The body form, stature, and hair are of the female 
type, but the individual may have a beard and the breasts may be 
poorly developed. The clitoris is large, resembling a penis, the 
labia majora are fused in the median line so that they are like a 
scrotum, and the vagina is small. 

For a complete exposition of this subject, with descriptions and 
illustrations of the many cases of hermaphroditism that have been 
reported, the reader is referred to Neugebauer's work ("Her- 
maphroditismus beim Menschen," 1908). 

INJURIES OF THE VULVA 

Injuries of the vulva may be divided into (a) those due to child- 
bearing, (6) those due to direct violence, and (c) those due to 
coitus. 

(a) Childbearing. — The labia majora are apt to be bruised and 
lacerated, more often the former, by the obstetric forceps. Lacera- 
tions are generally superficial, but may involve the vulvo-vaginal 
glands. Hematoma of the labium majus occurs occasionally follow- 
ing difficult labor and may attain great size. It is especially liable 
to occur in patients who have suffered with varix of the vulva 



INJURIES OF THE VULVA 401 

during late pregnancy. Hematoma is diagnosed by a tense swelling 
of a dark color, due to the clotted blood showing through the skin 
of the labium, and it is very sensitive on pressure. Such a hema- 
toma very seriously complicates labor. The nymphaB are torn now 
and then, but such wounds are seldom serious. The vestibule may 
be torn near the clitoris so that dangerous hemorrhage may result, 
but this is an unusual occurrence. Injuries of the hymen have 
been referred to under the malformations of the hymen, page 
396, and lacerations of the perineum are treated in the chapter on 
diseases of the vagina, page 372. 

(b) Direct Violence. — The vulva, because of its situation, is pro- 
tected from the more common forms of injury, but may be injured 
by falls astride of a sharp object, or by kicks, or blows. The close 
proximity of the unyielding bony arch of the pubes and the abun- 
dant blood supply of the parts make wounds in this region more 
serious. Women have fallen astride of a chair, or a pitchfork, or 
the saddle of a bicycle, or a fence picket, with resulting wound of 
the vulva, generally attended by excessive bleeding. Blows or 
kicks are apt to take effect on the labia majora with resulting 
hematoma, generally of one labium, and sometimes of considerable 
size. The hematoma may suppurate, become gangrenous, or, if not 
of a severe grade, may be absorbed. The dark blood generally 
shows through the skin; the hematoma is not often larger than a 
closed fist, and of course is very sensitive. Children have been 
injured by splinters of wood penetrating the vulva while sliding 
down a board, or by being thrown on sharp objects while 
coasting. 

(c) Coitus. — Injury of the hymen at the first intercourse often 
results in bleeding which has been known to be alarming in amount 
in very rare cases; usually the bleeding is of no moment. Severe 
injury of the vulva from rape upon young girls has been reported, 
the wound involving the perineum, labia, or even the recto- vaginal 
septum, there being cases on record where a recto-vaginal fistula 
resulted from brutal coitus. Disproportion in the size of the penis 
and the vagipa in the case of young girls and old women has given 
rise to injuries, which must be considered as of infrequent occur- 
rence. 



402 DISEASES OF THE VULVA 



INFLAMMATION OF THE VULVA: VULVITIS 

The vulva, being covered by modified skin and hair, is affected 
by the same sort of skin diseases as the other hairy parts of 
the body. The forms of skin diseases that most frequently affect 
the vulva are, erythema, eczema, herpes, acne, tuberculosis, con- 
dylomata, kraurosis, elephantiasis, thrush, pediculus pubis, syph- 
ilis, erysipelas, diphtheria, and gonorrhea. The last is the most 
frequent of the causes of inflammation of the vulva; other causes 
are, lack of cleanliness, irritating vaginal discharges, or irritating 
urine, as in diabetes mellitus, local irritation, as from scratching 
or an ill-fitting napkin, and, finally, any constitutional exhausting 
diseases that lessen the resisting power of the tissues. 

Simple or Catarrhal Vulvitis. — Simple or catarrhal vulvitis is the 
most common form of vulvitis and may be due to want of cleanliness, 
pediculi pubis, excessive coitus, abnormal discharges from the uterus, 
fecal or urinary fistula?, or malignant disease. In the acute form 
it is characterized by tenderness, burning and throbbing at the 
vulva, smarting on urination, and profuse, non-purulent discharge. 
In the chronic form itching and burning are noticeable symptoms, 
also a discharge that is thinner and less in quantity than in the 
acute stage of the disease. The vulva is congested and more or 
less swollen in its various parts and there may be excoriations or 
even ulcerations. In some cases the hair and sweat follicles are 
infected and the vulva is studded with papules and pustules. This 
follicular vulvitis is a rare form of vulvar inflammation seen mostly 
in the clinics of Europe. In diphtheritic vulvitis a characteristic 
gray membrane, composed of fibrin, is formed on the vulva, and a 
similar appearing membrane, but with little fibrin, also occurs in 
puerperal cases from the action of bacteria other than the Klebs- 
Loeffler bacillus, generally the streptococcus. The superficial 
inguinal glands take up infective matter from the vulva and even 
in the simple, catarrhal vulvitis may be enlarged. The disease has 
no tendency to invade the vagina or urethra and microscopic ex- 
amination shows the absence of the gonococcus. 

Gonorrheal Vulvitis. — In this variety, by all odds the most fre- 
quent form of vulvar inflammation, the disease has a tendency to 
invade the neighboring organs, and we have vaginitis, endocervi- 



INFLAMMATION OF THE VULVA 403 

citis, urethritis, and inflammation of Skene's and Bartholin's glands, 
as well as the vulvitis proper; the vulvitis, in fact, being the least 
important of the gonorrheal processes. The discharge is purulent 
and of a yellow or greenish-yellow color; the disease affecting the 
urethra early, there is burning, and frequent micturition from the 
beginning. The inguinal glands may be involved and a "bubo" 
is developed in the course of a few days; also, the vulvo- vaginal 
glands are apt to be infected. The diagnosis rests on the severity 
of the inflammation following a suspicious intercourse, on the 
presence of urinary symptoms, on being able to express a drop of 
pus from the urethra or one of Bartholin's glands, and on finding 
the gonococcus in the discharge. Gonorrheal vulvitis is not un- 
common among infants and little girls, especially in institutions, 
and may lead to adhesions of the labia minora or even the labia 
majora. The entire vulvar cleft may be closed except a small operi- 
ing either in front or behind through which the urine escapes. 
Lesser degrees of adhesions are by no means rare, and careful ex- 
aminations of the women who present themselves in the out-patient 
clinics will reveal many cases of agglutination of portions of the 
nymphse, or adhesions burying the glans clitoridis. 

Diabetic Vulvitis. — Diabetic vulvitis is an inflammation of the 
vulva caused by the decomposition of the urine in diabetes mellitus 
by the saccharomyces fungus. Its symptoms are burning and 
intense itching, and tenderness of the vulva. On inspection the 
vulva is of a dull, reddish color and the surfaces of the labia and 
vestibule are parchment-like, corrugated, and dry. Excoriations 
from scratching are to be expected, or even the presence of small 
boils, and in time the disease affects the skin of the mons veneris 
and the insides of the thighs and the anal region. The diagnosis is 
made by finding sugar in the urine and by the appearance of the 
vulva, which is most characteristic. 

Thrush of the Vulva. — This rare disease is caused by the Sacchar- 
omyces albicans, just as in the case of parasitic stomatitis. It is 
found most often in nursing women, in advanced diabetes, tuber- 
culosis, cancer and in women who are exhausted physically. The 
parts affected are covered with slightly elevated, snow-white spots, 
which have a tendency to coalesce and leave shallow ulcers. The 
saccharomyces fungus in the form of mycelium and spores may be 
found in the discharges scraped from the surface. 



404 DISEASES OF THE VULVA 

Elephantiasis of the Vulva. — Elephantiasis is extremely rare ex- 
cept in tropical climates. It affects mostly the labia majora, but 
may involve the clitoris or the nymphse. It occurs between the 
twenty-fifth and fiftieth years of life, and is characterized by 
thickening and enlargement of the tissues, sometimes forming a 
large tumor that has fissures and ulcerations on its surface. 

Pruritus Vulvae. — This is a symptom which may be due to a 
variety of causes, and consists of intense itching of the vulva. (See 
also Chapter X., page 160.) The various skin diseases such as eczema 
and pediculosis are characterized by itching, also the vulvitis due 
to diabetes, and the presence of Ascaris lumbricoides and Oxyuris 
vermicularis, especially in young subjects. Lack of cleanliness 
may cause itching and so may irritating discharges, as well as con- 
gestion of the vulva, as in varicose veins of the vulva and in preg- 
nancy. Aside from these definite causes the terminal nerve fila- 
ments in the vulva may be affected so that itching results, as in 
the case of some old women and in certain nervous diseases, and 
we are ignorant of the causation. For the purposes of prognosis 
and treatment it is important to determine, as far as possible, a 
definite cause. Great sensitiveness of the vulva may be due to a 
neuritis affecting the nerves of this region, and the physician will 
do well to rule out this affection before resorting to local treat- 
ment. 

Kraurosis Vulvae. — Kraurosis vulvas is a progressive atrophy 
and contraction of the tissues of the vulva of unknown cause, 
occurring mostly after the age of forty. The disease affects the 
nymphse, clitoris, and vestibule and begins as small brown spots, 
of irregular shape and slightly depressed, on the surface of the labia 
minora and the vestibule. Soon the tissues of the vulva become 
tense, shining, white, and contracted; the meatus urinarius pre- 
sents a reddened prominent appearance, and along the carunculse 
myrtiformes are small patches of subcutaneous hemorrhage. The 
nymphse atrophy. The orifice of the vagina becomes contracted 
so that it will barely admit the tip of a finger without causing 
hemorrhage or great pain. The pubic hair has a peculiar stubbly 
appearance and may be broken or may come out. The labia majora 
are not much affected by the atrophic process, as a rule. Micro- 
scopic examination of the tissues shows small- round-celled infil- 
tration and great development of fibrous tissue, with absence of 



INFLAMMATION OF THE VULVA 405 

hair follicles and sebaceous glands. Left to itself the disease runs 
a chronic course of five or six years. The symptoms are great 
irritation, smarting on urination, and painful intercourse, which 
may cause lacerations, the parts being very friable; the lacerations 
being severe if pregnancy and labor occur. The symptoms may be 
entirely relieved when the atrophic process has reached its 
climax. The diagnosis is established by the appearance of the 
vulva. 

Edema and Gangrene of the Vulva. — Edema of the vulva may 
occur as a result of vulvitis, but is more commonly the result of 
interference with the pelvic circulation by pressure on the pelvic 
veins by tumors, pelvic inflammatory masses, or the pregnant 
uterus, or it may form a part of a general anasarca. The nymphse 
and the prepuce of the clitoris are the parts mostly affected, but in 
extreme cases the labia majora and even the mons veneris become 
enormously distended. Pitting of the tissues on pressure is the 
diagnostic sign to be looked for. Gangrene may follow excessive 
edema or erysipelas of the vulva, or as a complication of the exan- 
themata, also in dirty, underfed children, where it is analogous to 
noma, or as an epidemic puerperal disease, or an acute inflammation 
independent of contagion. The nymphae are the portions of the 
vulva most affected by gangrene. It begins usually as a livid red, 
indurated swelling of one labium, soon breaking down into dirty 
gray or dull red ulcerations and followed by a greenish-black layer 
of gangrene. 

Varix or Varicose Veins of the Vulva. — Varix is found often during 
the later months of pregnancy. The enlarged veins are in the 
labia majora, and one or both sides may be involved, the left 
more often than the right. The vulva being well supplied with 
blood-vessels and also with erectile tissue, it is not surprising that 
obstruction to the veins should result in varix. The dark veins may 
be seen through the skin of the labium, and to the touch present 
the characteristic feeling of a bag of worms, as in the case of vari- 
cocele of the scrotum. Similar varicosities are to be found in the 
veins of the upper and inner thigh, and also in the vagina. 

Rupture of the veins of the vulva during delivery results in a 
hematoma of the vulva. 



406 DISEASES OF THE VULVA 



VENEREAL LESIONS OF THE VULVA 

Venereal lesions include chancroids, chancre, mucous patches, 
and condylomata lata and acuminata. 

Chancroids are most often found on the fourchette, the inner 
surfaces of the labia majora, the nymphse, and the vestibule; they 
are multiple as a rule, and are more common among the uncleanly. 
Secondary infection is usual and fresh chancroids keep appearing; 
and often some that seem to be healed break down and ulcerate 
anew. The lesion begins as a pustule that soon becomes an ulcera- 
tion; the ulceration has a punched-out undermined edge, a 
soft, non-indurated base, which has a granular, uneven surface 
covered by a purulent discharge. This discharge is auto-inoculable. 
The sore is sensitive to touch. The chancroid appears about forty- 
eight hours after an infecting coitus and develops rapidly. Second- 
ary infection of the lymphatic glands of the groin (a bubo) 
involves commonly only one gland in a severe grade of inflamma- 
tion, causing pain and often suppuration. 

Chancre of the Vulva. — This is relatively rare, an extra-genital 
situation of the initial lesion of syphilis being more frequent in the 
female than in the male. Also, because of the inaccessibility of 
the parts and the trifling discomfort to which they commonly 
give rise, chancres of the vulva often escape observation. The 
initial lesion of syphilis, if situated on the vulva, is generally to be 
found on the labium majus; the next most frequent situation is the 
fourchette, then the nympha?, the clitoris, and the mons veneris in 
order of frequency. The chancre appears as a hard, red lump which 
soon ulcerates; the induration of its base being a characteristic 
feature, also the enlargement, in six to ten days after its appearance, 
of the individual lymphatic glands in most intimate connection with 
it. The chancre appears after an average period of twenty-six days 
from the time of inoculation, and is nearly always single, but may 
be multiple if several abrasions have been inoculated at the same 
time. The ulcer formed by the chancre has smooth edges, often 
elevated or sloping, never undermined, and the base is of smooth 
surface and indurated, and the secretion, which is serous and 
scanty, is not auto-inoculable. The infection of the lymphatic 






VENEREAL LESIONS OF THE VULVA 407 

glands of the groins, primary adenopathy, affects several glands in 
a painless enlargement. 

Diagnosis of Chancre of the Vulva. — The diagnosis of chancre is 
often a matter of extreme difficulty. The discovery of the Spiro- 
chseta pallida in the secretions or a smear from the chancre makes 
the diagnosis sure, but failing this the three most important points 
are, the long period of incubation of the disease, the induration of 
the base of the sore, and the enlargement of the individual lym- 
phatic glands in the groin. 

A recent writer on the diagnostic significance of the spirochaeta 
pallida, R. P. Campbell, Jour. American Medical Association, Vol. 
LIV, March 19, 1910, page 924), speaks as follows from a large 
clinical experience in Montreal: "It should be possible to find the 
spirochaeta pallida in approximately 100 per cent of chancres ex- 
cluding those which are nearly healed, or have been actively treated, 
and some cases of mixed infection. In view of this fact, treatment 
should not be begun before the diagnosis is confirmed by finding 
the spirochete." 

Differential Diagnosis. — Herpes of the vulva is excluded by the 
appearance and the feel of the herpes: a superficial group of 
vesicles with a soft base disappearing after a short time. The 
crops of herpes may be multiple, while chancre is single. 

Furunculosis of the vulva has been mistaken for chancre. Here 
the boils are apt to be multiple and rim the usual course of a 
furuncle. The chief lesion that is confounded with chancre is the 
chancroid, and the distinguishing characteristics of the two lesions 
have been touched upon in the two preceding pages. 

Mucous Patches. — Mucous patches in the vulva are a frequent 
manifestation of secondary syphilis. They occur as moist papular 
syphilides and erosions, and have a discharge with a foul odor. 
The Spirochaeta pallida is abundant in scrapings from these patches 
and they are a most frequent source of syphilitic contagion. They 
are apt to be converted into condylomata lata or into a fusion of 
several papules to form cauliflower-like growths on the genitals, with 
fissures and ulcerations. Condylomata accuminata, occurring in 
cases of gonorrhea and unclean persons with irritating vaginal 
discharge, are not the same as the condylomata lata. The acum- 
inate variety are pointed, more wart-like, pedunculated, and of a 
branched, tree-like character. Their color may be that of the sur- 



408 DISEASES OF THE VULVA 

rounding skin, or, if the epithelium has been removed by friction or 
maceration, they are of a deep red hue. They have a foul discharge 
and may affect any portion of the vulva or the inner surfaces of the 
thighs, and may grow to the size of a fist. 

Gumma. — A gumma as a manifestation of tertiary syphilis may 
develop as a round tumor in the labium majus. It has a tendency 
to break down by a sort of fatty degeneration, but not to suppurate. 



TUBERCULOSIS OF THE VULVA 

This is a rare affection, there being on record only some fifteen or 
twenty cases. The disease is generally seen in the ulcerative 
stage in women between twenty and forty years of age, the ulcers 
being of a grayish color, of varying size, with irregular edges, ex- 
hibiting in their bases tubercles in process of cheesy degeneration, 
and friable, poorly nourished granulations. The ulcers are situ- 
ated in the vestibule or on the labia or perineum. The diagnosis 
is often difficult, numerous sections of the ulcerated tissues being 
made before tubercles and the tubercle bacilli are found. The 
inguinal glands are not affected in this disease; the ulceration pro- 
ceeds slowly, having a course of from eight to ten years, and there 
is no marked induration of the tissues. The disease has been called 
also lupus vulvae, and esthiomene de la vulve. 



CYSTS OF BARTHOLIN'S GLAND 

It is not surprising that the duct of the vulvo- vaginal gland, 
which is only half a millimeter in diameter at its exit, should become 
occluded as a result of infective inflammation, thus damming up 
the secretions. Gonorrheal inflammation is supposed to be a 
cause for the obliteration of the duct of the canal and therefore a 
cause of the formation of a cyst. Be that as it may, cysts of Bar- 
tholin's gland arc of sufficiently common occurrence. They are 
usually unilateral, vary in size from half a centimeter to four 
centimeters in diameter, and occur during the childbearing period 
of life. The smaller ones may be due to the occlusion of a second- 
ary, branching duct, rather than the main duct. 



ABSCESS OF BARTHOLIN'S GLAND 



409 



A cyst gives little trouble as a rule, though the larger ones may 
interfere with coitus; they are rarely painful. The patient gen- 
erally gives a history of old inflammation of the vulva. The 
diagnosis consists in detecting a fluctuating, not tender swelling in 
the situation of the vulvovaginal gland (see figures from Huguier). 

Cysts of the secondary ducts and of the gland itself are situated 




Fig. 174.— Cyst of the Left Bartholin's Gland. (After Huguier.) 

deeper in the tissues and farther from the introitus vaginas than 
cysts of the main duct, and such cysts may be multilocular, where- 
as cysts of the main duct are always unilocular. When laid open 
cysts of Bartholin's gland are found to be filled with a glairy, 
colorless, white-of-egg mucus, and to be lined by a smooth mem- 
brane. 

ABSCESS OF BARTHOLIN'S GLAND 



Abscess of the vulvo- vaginal glands is very common and is due, 
in a large proportion of cases, to gonorrhea. One gland at a time 
is affected, as a rule, more often the left, and the disease is generally 



410 



DISEASES OF THE VULVA 



met with in women under thirty years of age, who are likely to 
have gonorrhea, such as prostitutes and women of loose habits. 
The duct of the gland, or the gland itself, may be involved, Huguier 
having reported cases of the former. (See Fig. 175.) 

In severe and neglected cases the gland becomes disorganized. 
Huguier thought that cysts of the duct or gland become infected 
and suppurate. 

Suppuration in the gland or canal is apt not to come on until the 





■P 


V 




1 ?fc\ 




1 Obliterated 






excretory canaU / , 




Abscess of the 


1 N 


m 


ffl| ; ^K duct 


Abscess of duct , 


J \ 


K 6r/and 


laid opeq 


J' 





Fig. 175.— Abscess of the Ducts of Both Bartholin's Glands. (After Huguier.) 

later stages of gonococcus infection. Then there is a recurrence of 
heat and burning in the vulva with sharp pains, slight elevation of 
temperature, and tenderness of the tissues, the symptoms being 
aggravated by standing, walking, and sitting even, the patient 
being most comfortable in the recumbent posture. There may be 
retention of urine, or the urine simply smarts. Examination 
shows swelling and edema of the labium and sometimes pus escapes 



ABSCESS OF BARTHOLIN'S GLAND 



411 



from the orifice of the duct on the inner surface, or the abcess may 
be evacuated spontaneously through openings below the orifice. 
The inguinal lymphatic glands are affected sometimes and a " bubo " 
results. After the subsidence of the acute inflammation the vulvo- 
vaginal gland is apt to remain in a state of chronic inflammation 
and a drop of pus, perhaps with a greenish tinge, or a muco-puru- 




Fig. 176. — Abscess of Both Bartholin's Glands. (After Huguier.) A Drop 
of Pus is shown in the Orifice of Each Duct. Note Relation of Orifices to 
Introitus Vaginae. 



lent discharge issues from the duct. At this stage the orifice is 
surrounded by a red areola which resembles a flea bite, the so-called 
macula gonorrhoica of Sanger. It is in this stage that infection is 
apt to be transmitted to the male and light up in his urethra an 
acute gonorrhea, or it may cause puerperal sepsis or ophthalmia 
neonatorum. Relapse is common in abscess of Bartholin's gland 



412 DISEASES OF THE VULVA 

and the opposite gland may become infected, therefore prompt 
surgical treatment is indicated. Smears should be made from the 
discharges and examined for the gonococcus. 



DIFFERENTIAL DIAGNOSIS OF CYSTS AND ABSCESS 

In cases of long-standing inflammation the tissues may be so 
thickened that malignant disease is simulated. Microscopic ex- 
amination of tissue excised will establish the diagnosis. A rectal 
fistula discharging through the labium has been mistaken for an 
abscess of Bartholin's gland. Examination per rectum in such a 
case reveals brawny swelling, and the opening of the fistula in the 
bowel may be made out by means of the proctoscope and the 
probe. Hematoma of the labium makes a more uniform swelling 
than a cyst or abscess and feels doughy, also the skin is dark in the 
case of the hematoma and there is a history of injury or of recent 
parturition. Inguino-labial hernia appears in the upper part of 
the labium and tends to disappear when the patient lies down. 
There is an impulse on coughing, and in the case of hydrocele of 
the canal of Nuck the swelling is also in the upper part of the 
labium, but it is irreducible. Hydrocele of the Canal of Nuck is 
treated in the chapter on the diseases of the uterine ligaments. 
(See Chapter XII., page 213.) 

LABIAL HERNIA 

An inguinal hernia not infrequently finds its way into the labium 
majus and sometimes there is a double hernia of this sort. The 
hernia descends through the inguina canal and follows the course 
of the round ligament into the labium; this form of hernia being 
analogous to scrotal hernia in the male. The hernial sac may con- 
tain only omentum or it may hold intestine, the uterine tubes, the 
ovaries, or even the uterus. It is caused by the failure of the canal 
of Nuck to become obliterated. The patient complains of pains in 
the region of the hernia, especially on exertion, and is apt to suffer 
with dyspepsia and constipation. If the hernia is reducible the 
lump in the vulva disappears when the patient is in the recumbent 
posture. 



BENIGN TUMORS OF THE VULVA 413 

If the sac contains omentum the swelling is irregular in feel, 
provided the fat over the tumor is not excessive in amount, thus 
obscuring the tactile sense. The percussion note is flat and there 
is no gurgling sound in it when reduced and very little impulse on 
coughing. 

If the hernial sac contains intestine the swelling is smooth, regu- 
lar, and elastic. It is increased in size and becomes more tense on 
coughing or straining, and if reducible disappears or becomes 
smaller when the patient lies down. As the hernia goes back into 
the abdominal cavity a gurgling sound is heard. The tumor of the 
labium is tympantic to percussion and an impulse is transmitted 
to it when the patient coughs. 

Should an ovary be in the hernial sac pressure will cause pain 
similar to the pain experienced when the normal ovary is pressed 
between the fingers in a bimanual examination. 

If the uterus is in the sac bimanual examination of the pelvis 
will reveal the absence of the uterus from its usual situation. 

Differential Diagnosis. — Hernia into the labium must be differ- 
entiated from hydrocele of the canal of Nuck, from a tumor of the 
labium, or a cyst of Bartholin's gland. From the first it is distin- 
guished by the fact that it is tympanitic, has an impulse on coughing, 
may have an irregular contour, is reducible, and has gurgling on 
reduction. Hydrocele is irreducible, is of smooth outline, has no 
impulse, and is flat to percussion. A solid tumor of the labium is 
generally of hard consistency; it projects from the surface, has 
no impulse on coughing and no gurgling. A cyst of Bartholin's 
gland is globular, has no impulse, is flat to percussion, and is situ- 
ated in the lower part of the labium, whereas a hernia is oval, has 
an impulse, may be tympanitic, and is in the upper part of the 
labium. 

BENIGN TUMORS OF THE VULVA 

These are fibroma, myoma, myxoma, neuroma, angioma, lipoma, 
and cysts. They are rare. Most of them affect the labia majora. 
J. Bondi has found three sorts of cysts of the labia minora, of which 
the mucous cysts are the most frequent. He thinks they represent 
remains of the Wolffian bodies. They are situated in the upper part 
of the labium. Lipoma may grow from the fatty tissue of the 



414 DISEASES OF THE VULVA 

mons veneris or the labia majora, or even from the nymphae, and 
may attain considerable size. The diagnosis of benign tumors 
can not be made exactly, short of removal and microscopic ex- 
amination of the tissues of the tumor. Slow growth is the rule, and 
the only symptoms are interference with coitus and the discomfort 
attending the presence of the growth. 



MALIGNANT TUMORS OF THE VULVA 

These are cancer and sarcoma. 

Cancer. — Primary cancer of the vulva is rare. It is a disease of 
advanced life, usually occurring between the ages of forty-five and 
sixty. Its most frequent point of origin is the groove between 
the nympha and the labium majus, but it may develop from the 
prepuce of the clitoris or any of the structures of the vulva. The 
cancer appears in one of three forms, as a circumscribed elevation, 
as a deep ulceration with infiltrated margins, or as a diffuse infil- 
tration. The circumscribed growth is a firm tumor rising from 
the surface of the vulva and more or less movable on the under- 
lying, infiltrated tissues. If the cancer has broken down it is a 
friable lobulated or warty mass, showing points of ulceration. The 
surface is granular, furrowed, and bright red in color, and the base 
is indurated. The carcinoma may invade the deeper tissues from 
the beginning, not forming a circumscribed growth on the surface. 
In this case the tissues become of a brawny hardness and are 
thickened over an area of considerable extent. This sort of growth 
may progress very slowly, and ulceration may not appear for 
several years. The tendency of the disease is to involve the struc- 
tures of one side of the vulva and then to extend to the opposite 
side, perhaps by inoculation. The lymphatic glands of the groin 
are involved early, and the individual glands are to be distin- 
guished as separate, hard lumps. 

Cancer of Bartholin's gland occurs as a round, indurated tumor, 
often as large as a hen's egg, in the lower portion of the labium 
majus. The tumor is generally very vascular, and large vessels 
can be made out in the overlying skin. 

Cancer of the vulva is of the type of squamous-celled carcinoma, 
and cancer " pearls," due to horny degeneration of the centers of 



MALIGNANT TUMORS OF THE VULVA 415 

the epithelial nests, are abundant. Like cancer in other situations 
in the genital organs, this form of cancer has no symptoms which 
are peculiar to itself. Pain is a late symptom after the disease 
has extended and involved the larger nerve trunks. Ulceration 
causes local tenderness and a discharge. 

Differential Diagnosis of Cancer. — In the early stages of cancer 
the following diseases must be excluded : tuberculosis, condylomata 
lata and acuminata, chancre, chancroids, and urethral caruncle. 
Tuberculosis occurs in younger women, i.e., between twenty and 
forty years of age, and is of slower growth; the nodules are mul- 
tiple and soft, the induration of the base being absent; tubercles 
may often be seen in the cheesy degenerated areas; and the in- 
guinal glands are not involved. The microscope will settle a doubt- 
ful diagnosis. It is to be remembered that the two diseases are 
both present sometimes in the same case. The two sorts of condy- 
lomata are excluded by the history; in the case of condylomata 
lata there is a history of syphilis, and in condylomata acuminata, 
of gonorrhea; also by the absence of ulceration and pain. 

Chancre in its early stages may resemble cancer. In the former 
there is a history of infection followed by a definite period of in- 
cubation, twenty-six days. The initial lesion is not painful, its 
ulcer shows no tendency to spread to the surrounding tissues, and 
its discharge is scanty, muco-purulent, and thin, as opposed to the 
profuse purulent discharge of the cancerous ulcer. If the Spiro- 
chseta pallida can be found in smears from the surface the diag- 
nosis of chancre is made certain. Also, the secondary symptoms 
of syphilis are developed within six weeks after the appearance of 
the initial lesion. 

Chancroids are preceded by a history of infection two clays or so 
before the development of the ulcers, which are generally multiple. 
Only one lymphatic gland at a time is involved as a rule in chan- 
croids, and the gland tends to suppurate ; in cancer several glands 
are affected and they do not suppurate. The chancroid ulcers are 
punched out, with undermined edges, and their bases are of smooth 
surface, and are not indurated. The ulcer from chancre is single, 
it has sloping edges, and a rough and indurated base. Urethral 
caruncle occasionally simulates beginning cancer. Caruncle is, 
however, of soft consistency. When ulcerated it should be removed 
promptly and subjected to a microscopic examination. 



416 DISEASES OF THE VULVA 

Sarcoma of the Vulva. — Primary sarcoma of the vulva is ex- 
tremely rare and occurs in young subjects as a rule. The melanotic 
variety is the one most often found, but spindle-celled and round- 
celled forms have been reported. In the melanotic variety the 
lesions are multiple and appear as hard, round nodules several 
centimeters in diameter, of a black or brown color, and originating 
in warts, moles, or nsevi. The nodules tend to coalesce and to 
become ulcerated, but do not attain great size. In the other 
varieties the nodules are generally single, grow rapidly, and may 
attain considerable proportions, even as large as a man's head. 
They do not ulcerate and the lymphatic glands are rarely affected. 



CHAPTER XXII 

THE DIAGNOSIS OF UTERINE PREGNANCY, ABORTION, 
AND HYDATIDIFORM MOLE 

Diagnosis of normal uterine pregnancy, p. 417: During the first three 
months, p. 418; History, p. 418, Amenorrhea, p, 419, Nausea and vomit- 
ing, p. 419, Salivation and minor digestive disturbances, p. 420, Breasts, 
p. 420, Leucorrhea, p. 420, Bladder disturbances, p. 420; Inspection and 
palpation, p. 420, Breasts, p. 421, Areola, p. 421, Inspection of the vulva and 
vagina, p. 421, Bimanual touch, p. 423. During the last six months, p. 
426; History, p. 426, Quickening, p. 426; Inspection and palpation, p. 426, 
Gait, p. 426, Figure, p. 426, Breasts, p. 426, Secondary areola, p. 426, Vulva, p. 
427, Bimanual touch, p. 427, Internal ballottement, p. 429, Abdomen, p. 427; 
Auscultation, p. 429, Tabular statement of symptoms and signs of pregnancy 
by months, p. 430. Differential diagnosis of normal pregnancy, p. 431; 
During the first three months, p. 431, Anteflexion, p. 431, Chronic subin- 
volution, p. 431, Fibroid in the anterior wall, p. 431, Retroflexion, p. 431, 
Extra-uterine pregnancy, p. 431; During the last six months, p. 432. 

Diagnosis of abnormal uterine pregnancy, p. 432: Diagnosis of retro- 
flexion and incarceration of the pregnant uterus, p. 432. Diagnosis of 
interstitial pregnancy and of pregnancy in a rudimentary horn of a 
bicornute uterus, p. 433. Diagnosis that pregnancy has occurred previously, 
p. 433. Diagnosis of multiple pregnancy, p. 434. Diagnosis of pernicious 
vomiting of pregnancy, p. 434. 

Diagnosis of abortion, p. 436: Definitions, p. 436. Frequency, p. 437. 
Etiology, p. 437. Symptoms, p. 438. Diagnosis, p. 439; Diagnosis of 
threatened abortion, p. 439; Diagnosis of inevitable abortion, p. 439; 
Diagnosis of abortion partially or wholly completed, p. 440; Diagnosis 
of miscarriage, p. 440. Differential diagnosis, p. 440. 

Diagnosis of hydatidiform mole, p, 441: Pathology, p. 441. Symptoms, 
p. 443. Diagnosis, p. 443. 



THE DIAGNOSIS OF NORMAL UTERINE PREGNANCY 

The diagnosis of normal uterine pregnancy offers often many 
difficulties to the practising physician and is perhaps the most 
important department of diagnosis. Vander Veer collected seventy- 
seven instances of abdominal operations on supposedly pathological 
growths, some of the operators being men of note, where the pa- 
tient was pregnant in each instance. Hirst mentions the fact 
27 417 



418 NORMAL UTERINE PREGNANCY 

that a gynecologist on the staff of a large hospital has twice oper- 
ated for fibroid tumors of the womb, and only after the amputation 
of the uterus found that it was pregnant, and not the seat of a 
fibroid tumor at all. Both patients died. I have seen the same 
thing happen in the experience of a prominent surgeon to one of 
the largest hospitals, although the subsequent fate of the patient 
was unknown. I have also known of a surgeon of large experience 
operating for ovarian tumor on the wife of a noted obstetrician, 
the diagnosis being made by the apprehensive husband and by an 
internist, the operation proving that there was no ovarian tumor, 
the excessive abdominal enlargement being due to pregnancy and 
hydramnios. Mistakes are so frequent that no excuse is necessary 
for occupying space in describing a subject which, by a strict in- 
terpretation, belongs in the domain of obstetrics. 

The diagnosis of pregnancy depends on the history; on inspection 
of the face, neck, figure, breasts, abdomen, and vagina; on the bi- 
manual examination, and, in the later months, on auscultation of 
the abdomen. 

During the First Three Months of Pregnancy 

The diagnosis of pregnancy before the fetal heart sounds are 
heard or fetal movements felt in the fifth or sixth month is not an 
absolute certainty; still, the strongest sort of a probability may 
be expressed if all the facts are taken into consideration. The 
demonstration of the changes in the genital organs due to the in- 
creased blood supply and the growth of the ovum form the basis of 
a diagnosis; contributory facts are the alterations in the breasts, 
the body form and carriage, and the effects on the nervous system. 

History 

To get the history of pregnancy is not always an easy matter, 
for patients not infrequently conceal the facts either because, in 
the case of the unmarried, they hope the physician may pass a 
sound into the uterus and cause abortion, or they are ashamed to 
acknowledge immorality, or, in the case of those pregnant for the 
first time, because of inaccurate observation. . Patients who have 
been pregnant previously can say sometimes that pregnancy began 
with a particular coitus when especially pleasurable sensations 



FIRST THREE MONTHS OF PREGNANCY 419 

were experienced, also morbid cravings for special sorts of food or 
disturbances of digestion have been the same as with former preg- 
nancies. 

Amenorrhea. — Absence of menstruation is one of the chief symp- 
toms of pregnancy. In questioning the patient the exact date of 
the beginning of the last menstruation should be obtained and also 
how long it lasted, and whether it was in all respects similar to the 
usual menstrual periods. Did coitus occur soon after this period? 
The end of the last catamenia is the date from which the beginning 
of pregnancy is usually reckoned. If the patient has been always 
regular in her menstruation, amenorrhea of two months is a most 
suspicious circumstance; if, on the other hand, she has been 
habitually irregular or if she is nursing a baby, so much importance 
can not be attached to it. Cases are on record where menstruation 
has occurred at irregular intervals during the entire pregnancy; 
in fact, one or two shows of blood during the first few months are 
by no means uncommon. About half of all nursing women men- 
struate during lactation, and as the number of pregnancies in- 
crease the tendency to menstruate while nursing increases also, 
therefore amenorrhea during lactation is not a constant sign. 
Baudelocque, Deventer, and others have reported instances of 
regular menstruation occurring only during gestation, but such 
cases are rare. Amenorrhea may occur in chlorosis, maldevelop- 
ment of the uterus, or the beginning of the menopause, in tuber- 
culosis, obesity, acute constitutional diseases, prolonged lactation, 
chronic poisonings, particularly lead, or from change of climate, 
or profound mental disturbance. Amenorrhea is common in girls 
who have immigrated from a foreign country. A majority of the 
Irish girls seen in the out-patient clinics of Boston have amen- 
orrhea for several months after arriving in this country. Acro- 
megaly, occurring as it generally does in young subjects, is apt to 
have complete amenorrhea as one of its first symptoms, and tu- 
mors of the base of the brain, especially those involving the hy- 
pophysis cerebri, as pointed out by Harvey Cushing, have amen- 
orrhea as a prominent symptom. 

Nausea and Vomiting. — The morning sickness of pregnancy is a 
fairly common but by no means an invariable accompaniment of 
gestation. It varies from an occasional qualm to active nausea 
and vomiting occurring when first assuming the erect posture in 



420 NORMAL UTERINE PREGNANCY 

the morning. Some patients can not brush their teeth without 
being nauseated. The symptom does not manifest itself as a rule 
until the fourth or fifth week, but may begin as soon as ten days 
after conception. It occurs also in BrigmVs disease, gastritis, and 
chlorosis. These diseases must be ruled out, and if there has been 
a previous pregnancy, nausea and vomiting will probably have 
occurred with it. The symptom must be regarded as due to the 
enlargement and stretching of the uterine muscle fibers and nerves. 
The nausea may occur at other times than in the morning and may 
persist throughout pregnancy, although it generally ceases after 
the third month. 

Salivation and Minor Digestive Disturbances. — An excessive flow 
of saliva, heartburn, eructations, and abnormalities in appetite 
such as longings for strange or unusual articles of food, are not 
unusual accompaniments of pregnancy. Occasionally patients are 
seen who enjoy better digestion and even better general health 
while they are pregnant than at any other time. 

The Breasts. — A sensation of weight and fullness in the breasts, 
often accompanied by tingling sensations, is common to pregnancy, 
and patients who are observant note greater prominence of the 
nipples, and enlargement of the follicles in the darkened areolae. 

Leucorrhea. — There is a marked increase in vaginal discharge 
during pregnancy. This is noted early with the occurrence of the 
engorgement of the genitals; but, of course, leucorrhea may be due 
to other causes. It is seldom that the increase in the discharge in 
early pregnancy is enough to attract the patient's attention. 

Bladder Disturbances. — Increased frequency of micturition is a 
most common accompaniment of early pregnancy, probably due to 
congestion of the vesical trigone coincident with the physiological 
hyperemia of the uterine organs. 

Inspection and Palpation 

Since the days of Hippocrates and Democritus certain changes 
in the face and neck have been observed in pregnant women. The 
eyes seem to be deeper set, and may have bluish circles under 
them; there are brownish-yellow blotches upon the skin of the 
cheeks, which are fuller than usual, and the neck seems larger than 
when the woman is not pregnant. Too much importance is not to 



FIRST THREE MONTHS OF PREGNANCY 421 

be attached to these signs, which may be entirely absent. Still, 
one or more of the changes will be found not infrequently if oppor- 
tunity is afforded for careful observation of the patient both before 
and during pregnancy. 

The Breasts. — Enlargement. — The breast enlargement of preg- 
nancy presents a firm, irregular feeling on palpation, and not the 
smooth, soft swelling due to increase of fatty tissue. The hard, 
knotty sensation is due to the increase in the size and number of 
the lobules of the mammary gland. In the early months this change 
is to be distinguished most clearly at the outer edges of the gland. 

The veins of the entire breast are enlarged, forming a blue tra- 
cery under the skin, most marked in the neighborhood of or in the 
areola. They show better in persons with white, thin skins. 

The Areola. — The circular area upon which the nipple stands in the 
non-pregnant woman, of a pinkish or somewhat pigmented color 
according to the type of the individual, darker in brunettes and 
lighter in blondes, under the influence of gestation becomes darker 
in color. Even in the light blonde the customary pink color is 
deepened; in the brunette the areola becomes the color of the skin 
of a quadroon. In fair women the areola may be elevated above 
the surrounding skin; this feature is brought into prominence by 
stretching the skin of the rest of the breast. When stimulated by 
a touch of the finger tip the surface of the areola will wrinkle up or 
pucker. The wrinkling brings into prominence the enlarged se- 
baceous follicles, some twelve to twenty in number, which project 
about a sixteenth of an inch above the surface of the areola. 

The value of the mammary signs is greater in first pregnancies 
because many of the characteristics, such as enlargement and the 
appearances of the areola, persist after the termination of the 
first pregnancy. One must rule out previously existing uterine or 
ovarian disorders, or masturbation, because in these conditions 
the breast appearances are often the same as in pregnancy. The 
mammary signs are among the earliest of the indications of preg- 
nancy and are especially valuable as indicative of the probable 
condition in the case of the unmarried where it is necessary for 
the physician to proceed with caution. A physical examination of 
the chest gives opportunity to inspect the breasts, and their showing 
sometimes warrants further investigation. 

Inspection of the Vulva and Vagina. — On separating the labia the 



422 NORMAL UTERINE PREGNANCY 

vagina will be found to be abnormally moist and covered with 
whitish shreds of desquamated epithelium, and the anterior vag- 
inal wall just under the urethra shows a dusky, purplish discolora- 
tion sometimes called Jacquemin's sign because first noted by this 
author in 1837. The discoloration is to be seen first in the bottoms 
of the furrows of the mucous membrane, therefore it is well to put 
the anterior vaginal wall on the stretch. This sign may be apparent 
as early as the end of the first month and is present in over half of 




Fig. 177.— Diagrammatic Side View of the Pregnant Uterus of the Sixth Week, 
during Relaxation. (After Dickinson.) 

all cases by the end of the third month. It is more distinct in mul- 
tipara) and is more apt to be absent in primiparse. 

Speculum examination of the upper vagina shows the cervix to 
be of a purplish color, soft to the feel, and in primiparse the os 
tincsc becomes rounder. Erosions arc of a deeper purple color than 
the surrounding tissues. Many observers consider the discoloration 
of the cervix an earlier and more constant sign than Jacquemin's 
sign. As congestion of vagina and cervix may be found in pelvic 
disease, such as large ovarian and uterine tumors obstructing the 
venous circulation, and in certain constitutional diseases, as heart 



FIRST THREE MONTHS OF PREGNANCY 423 

disease and cirrhosis, the physician must be on his guard. The 
typical discoloration of pregnancy is, however, limited to the lower 
anterior vaginal wall, about the lower urethra, and to the cervix; 
whereas in pelvic disease and constitutional disorders the con- 
gestion is general. 

The Bimanual Touch. — This is practised w T ith the patient in the 
customary dorsal position (see page 33). The finger notes a soft 
cervix. It is to be remembered that softening of the cervix is 




Fig. 177a. — The same, during Contraction. 

found also in septic conditions of the uterus, as in septic endome- 
tritis, so that a soft cervix is not pathognomonic of pregnancy. 
The uterus itself is a little lower in the pelvis than normal, and is 
enlarged by the growing ovum, which is usually attached to the 
endometrium in the neighborhood of the orifices of the tubes. The 
uterus grows faster than the ovum at first, and the ovum with 
its envelopes does not fill the uterine cavity until the end of the 
third month, when the decidua reflexa joins the decidua vera. 

The first change in shape noted in the gravid uterus consists in 
a slight enlargement of its transverse diameter; then it becomes 
lengthened and fatter as the ovum increases in size, especially in 



424 



NORMAL UTERINE PREGNANCY 



the anterior part of the body of the uterus; this anterior bulging 
being quite characteristic in many cases. Asymmetry is caused 
by the development of the ovum in one cornu, a not uncommon 
happening. Uterine enlargement may be detected by the practised 
hand as early as the sixth week; in the third month there can be 
no doubt about it, even to the tyro. The softening of the uterus 
varies in different individuals and at different times in the same 
individual. It is less in primiparse than in multipara, but under 




Fig. 178. — Six-weeks' Pregnant Uterus with Elongation of Cervix, Showing 
Extent to which its Cavity Is Occupied by the Ovum. O.E., external os; 0.1. , 
internal os; D.V., decidua vera; D.S., decidua serotina; D.R., decidua reflexa; 
Emb., embryo; P., placenta. (Williams.) 



the influence of pregnancy there is always an increase in elasticity of 
the organ. Even as early as the first weeks the rhythmical contrac- 
tions which go on throughout pregnancy may be felt by patient 
bimanual palpation. They involve the entire uterus and are ex- 
cited by any manipulation of the organ, therefore the bimanual 
examination should last from five to ten minutes so that sufficient 
time may be afforded for contractions to take place. Ellice Mc- 
Donald (Amer. Jour. Obstet., LVIL, 1908) observed intermittent 



FIRST THREE MONTHS OF PREGNANCY 



425 



contractions in 88 out of 100 cases of early pregnancy examined 
with reference to diagnosis. The lower uterine segment is the 
portion of the uterus where the softening is most manifest. The 
softening at this point is called Hegar's sign and can be determined 
only during uterine relaxation. The upper portion of the uterus, 
being occupied by the ovum, is tense and elastic ; below the ovum 
the soft uterine tissues may be compressed between the ringer in 




Fig. 179.— Bimanual Palpation of Early Pregnancy for Hegar's Sign. (Williams.) 

the vagina and the fingers of the abdominal hand brought down 
either in front of the uterus or behind it, generally the latter. 
(See Fig. 179.) 

Very early in pregnancy palpation with the abdominal hand in 
front of the body of the uterus and the vaginal finger behind the 
cervix is sometimes available, especially in cases of retroversion; 
later in pregnancy, when the uterus has become longer and more 



426 NORMAL UTERINE PREGNANCY 

anteflexecl, the fingers of the abdominal hand are brought down 
behind the fundus, while the finger in the vagina is placed in front 
of the cervix. The softening of the tissues of the lower uterine 
segment makes this portion of the uterus more flexible than in the 
unimpregnated state. Downward pressure by the abdominal hand 
on the top of the fundus during a period of relaxation, while the 
vaginal finger under the crown of the cervix makes upward pressure, 
causes the uterus to bend in the weakest part, the softened area. 
McDonald found this increased flexibility in ninety-seven out of his 
one hundred cases. 

During the Last Six Months of Pregnancy 
History 

The history is the same, except that nausea and vomiting and 
digestive disturbances cease after the third month, and the bladder 
symptoms are apt to be less. Abdominal enlargement is noticeable 
now, and the patient has to let out her dresses. Quickening, or the 
sensation caused by the fetal movements, is felt from the sixteenth 
to the eighteenth week of gestation, some women detecting it 
earlier than others. 

Inspection and Palpation 

The Gait. — In the later months the pregnant woman walks with 
a backward pose, the abdomen, more or less enlarged, being prom- 
inent in front. Ask her to walk up and down the office and note 
her gait. Also, the sacro-iliac and pubic joints of the pelvis are 
relaxed during later pregnancy; in women with sacro-iliac disease 
the motion is excessive, and the gait is decidedly wobbly; in other 
women the gait may be little if any affected. 

The Figure. — The prominent breasts and protuberant abdomen 
will be noticeable if the physician has been acquainted with his 
patient previous to pregnancy. 

The Breasts. — Besides the changes in the breasts noted as to be 
found during the first three months, there appears at the fifth month 
a secondary areola outside the primary areola which is next to the 
nipple, consisting of a network of pigment around light spots, 
each spot representing a circle round the opening of a sebaceous 
follicle. These light spots may extend all over the breasts, but are 



LAST SIX MONTHS OF PREGNANCY 427 

most marked next to the primary areola. Skillful stroking of the 
breast toward the nipple will force colostrum from the nipple after 
the third month. This is a valuable sign of pregnancy, although 
milk has been found in the breasts of virgins and even in young 
children of precocious development. 

The Vulva. — The vulva, vagina, and cervix have the same ap- 
pearance as during the first three months, except that the engorge- 
ment of the tissues is now more marked. The vaginal discharge is 
increased in amount. 

The bimanual touch detects the fetus by internal ballottement 
after the fourth month, for by this time the quantity of liquor 




Fig. 180. — Primary and Secondary Areolae in a Brunette. ("American 
Text-Book of Obstetrics.") 

I 

amnii is sufficient, and the fetus is large enough to permit the 

examiner to feel its bobbing about in the uterus. Ballottement 
may be practiced with the patient in the dorsal or in the standing 
position, preferably the latter. The physician introduces one or 
two fingers into the vagina and makes a quick, sharp, upward 
push against the uterus. In a moment the fetus, which is heavier 
than the fluid in which it is suspended, settles against the examin- 
ing finger with a distinct tap. This sign is available during the 
fifth and sixth months. After that the fetus has grown so large 
that it can not be moved about freely. After the seventh month 
the cervix is very soft and the os is patulous. 

The Abdomen. — Pigmentation of the linea alba of the abdomen 
is noticeable, especially in brunettes, after the third month. It 
consists of a dark line about half an inch wide extending from the 



428 



NORMAL UTERINE PREGNANCY 



symphysis pubis around the navel to the tip of the ensiform car- 
tilage. In the later months of pregnancy streaks of white or pink 
appear in the skin of the flanks, the breasts, and the lower abdomen, 
the so-called linese albicantes. 

The protrusion of the abdomen in pregnancy after the fifth or 
sixth month is generally asymmetrical, being more marked on the 
right. The umbilicus is apt to protrude in the last two months. 





' 




1- 


. \ . 





Fig. 181. — Enlargement of the Uterus at the Different Weeks of Pregnancy. 
("American Text-Book of Obstetrics.") 



The fundus uteri is two or three fingers' breadth above the sym- 
physis at the end of the fourth month and reaches the umbilicus 
at the close of the sixth month. 

The parts of the fetus may be felt in favorable cases by the 
twentieth week (the fifth month), being a most valuable sign of 
pregnancy. Excess of liquor amnii, a rigid and thick abdominal 



LAST SIX MONTHS OF PREGNANCY 429 

wall, or tense uterine walls prevent the detection of the fetal parts. 
Fetal movements can be felt by the end of the sixth month with a 
fair degree of constancy and often much earlier. Placing the hand 
quietly on the abdomen it is allowed to rest there for several min- 
utes. A very gentle throb is felt if in the sixth month, later the 
movements are stronger. During the sixth month external ballotte- 
ment may be practised, a hand on each side of the abdomen being 
able to push the fetus to and fro; also intermittent uterine con- 
tractions, rhythmic and painless, occurring every five to ten 
minutes and lasting a minute or two, may be distinguished by 
placing the hand on the abdomen and waiting. A sudden motion 
with the hand or a cold hand will often cause a contraction. These 
contractions can be made out through the abdomen after the 
fourth month, but are to be felt by bimanual touch from the begin- 
ning of pregnancy. . A uterus distended by retained menstrual 
blood or by an intra-uterine tumor has these same rhythmical 
contractions. 

Auscultation 

The fetal heart sounds are proof positive of pregnancy. Oc- 
casionally they may be heard toward the end of the fourth month, 
but as a rule are not available as a means of diagnosis before the 
end of the fifth month. The entire anterior surface of the uterus 
must be explored with the stethoscope because of the variable 
position of the fetus, but the most usual situation is between the 
umbilicus and the left anterior superior spine of the ilium, because 
the back of the child is situated there in the commonest position, 
left occipito-anterior. The heart beat has been likened to the 
ticking of a watch under a pillow; it is double and has a rate of 
120 to 150 beats a minute, being increased by the activity of the 
child, by fever of the mother, and at the begining of a uterine 
contraction, variations of twenty beats a minute being often 
observed in the same fetus. A uterine souffle, synchronous with the 
mother's pulse and heard best along the left side of the uterus, 
becomes audible during the fourth month and is a sign of an en- 
larged uterus, but not necessarily of pregnancy because it is heard 
also in large fibroids. 

A summary of the symptoms and signs of pregnancy by months, 
modified from Dickinson, is appended. 



430 



NORMAL UTERINE PREGNANCY 



Summary of Symptoms and Signs of Pregnancy by Months. 





History. 


Breasts. 


Abdomen. 


Pelvis. 


Miscellaneous 


1. 


Amenorrhea 
throughout 
all months. 




















2. 


Nausea. Swell- 
ing and tin- 
gling of 
breasts. 
Frequency 
of micturi- 
tion. 


Enlarged. 
Veins show. 
Areola pig- 
m e n t e d. 
Follicles. 




Leucorrhea. 
Purplish 
discolora- 
tion vagina. 
Bulging an- 
terior fun- 
dus. Com- 
pressibility 
of lower seg- 
ment. Soft 
cervix. 










3 


Ditto 


Ditto 




Ditto 


Swelling of face 
and neck. 








4. 


Nausea ceases. 


Colostrum. . . . 


Beginning en- 
largement. 
Pigmenta- 
tion of linea 
alba. 


Cervix softer. 
Fetal parts 
felt. More 
congestion 
of vagina. 


orations. 


5. 


Quickening . . 


Secondary 
areola. 


Fetal heart 
sounds 
heard. Fetal 
parts felt. 
Uterine 
contrac- 
tions felt. 
Uterine 
souffle. 


Internal bal- 
lottement. 








6. 


Ditto 


Ditto 


Fetal move- 
ments. Ext. 
ballotte- 
ment. Lin- 
ea3 albican- 
tes. Fundus 
reaches um- 
bilicus. 


Ditto. ....... 

Cervix high- 
er in the 
pelvis. 


Gait unsteady. 

Backward 
. pose. Promi- 
nent breasts 
and abdo- 
men. 


7. 


Ditto 


Ditto 


Ditto 


No ballotte- 
ment. 


Ditto 


8. 






Abdomen pro- 
gressively 
larger. 


Cervix very 
soft and os 
patulous. 




9. 









DIFFERENTIAL DIAGNOSIS 431 



Differential Diagnosis of Normal Pregnancy 

It has been my experience that in early pregnancy a malfor- 
mation of the uterus or a tumor of the uterus is most often mistaken 
for pregnancy, whereas in the later months an ovarian tumor is 
frequently confused with the pregnant uterus. It may be well to 
mention some of the most common mistakes in diagnosis, although 
there are so many that the advice as to the later months to regard 
all enlargements of the abdomen as due to pregnancy until the 
contrary has been proven, is certainly safe to follow. 

During the First Three Months 

Anteflexion with retroposition may closely simulate early pregnancy, 
especially if there is congestion of the cervix and an endometrial 
discharge. In anteflexion the cervix is not soft, there is no purplish 
discoloration of the anterior vagina, the corpus uteri is not elastic, 
the lower uterine segment is not compressible, there are no rhyth- 
mical contractions, and menstruation still persists, though irregular. 
An examination several weeks later shows the signs to be the same 
as at the last examination, and, additionally, markedly anteflexed 
uteri are generally sterile. 

Chronic subinvolution shows an enlarged uterus, but the tissues 
are firmer than normal, the body is not globular in shape or bulging 
anteriorly, and the lower uterine segment is not compressible. 
Purplish discoloration is absent. Menstruation, though scanty, 
is present. 

Fibroid of the anterior wall is of hard consistency; menstruation 
is present, purplish discoloration is absent, rhythmical contrac- 
tions may be present. Upon a second examination after an interval 
of two weeks or more, the sound may be passed and the situation 
and size of the fibroid determined. 

Retroflexion. — The congested fundus may simulate a gravid 
uterus. The uterus should be replaced as described in Chapter 
XIV., page 237, and another examination made in the course of a 
few days. 

Extra-uterine pregnancy is considered in Chapter XIX., page 340. 

It is always wise not to hurry in making a diagnosis in doubtful 
cases and ask for another examination, if necessary with an anes- 



432 ABNORMAL UTERINE PREGNANCY 

thetic. Nothing is to be lost and often much gained by adopting 
such a course. 

During the Last Six Months 

In the case of enlargements of the abdomen due to other causes 
than pregnancy the rate of enlargement does not coincide with 
that of the gravid uterus; if amenorrhea is present the duration 
of the absence of the menses does not correspond with the size of 
the tumor, supposing it to be pregnancy; and the distinctive signs 
of pregnancy are absent, namely, the fetal heart sounds, fetal parts 
felt, fetal movements felt, and internal and external ballottement. 
Menstruation usually persists. The differential diagnosis of ova- 
rian cysts, fibroid tumors, phantom tumors, and fat in the abdom- 
inal wall, distended bladder, ascites, tympanites, and the very 
rare hematometra, will be found in the chapter devoted to those 
subjects as shown in the index and need not be repeated here. In 
cases of rigid abdominal walls more than one examination and, 
in very doubtful cases, an anesthetic is indicated. 



THE DIAGNOSIS OF ABNORMAL UTERINE PREGNANCY 

The Diagnosis of Retroflexion and Incarceration of the Pregnant 
Uterus. — This not uncommon condition is characterized by a 
tumor of elastic consistency filling the pelvis, the cervix being high 
up behind the arch of the pubes. The symptoms and signs of 
pregnancy are present and in addition there are apt to be pelvic 
pains and retention of urine. Before attempting to replace the 
uterus a careful investigation of the urinary function should be 
made and queries asked whether there has been stoppage of urine 
or whether any bits of tissue have been passed with the urine, or 
the patient has suffered with symptoms of cystitis. Krukenberg, 
who with Rivington collected twenty cases of rupture of the 
bladder occurring in cases of incarcerated retroflexed pregnant 
uteri, advises against replacement of the uterus whenever there 
have been passed by the urethra portions of necrotic bladder wall 
because of the clanger of rupturing the bladder during replace- 
ment. He prefers to practice abortion. In any event the bladder 
should be thoroughly emptied by catheter before attempts at 



INTERSTITIAL PREGNANCY 433 

replacement are carried out. These are done by placing the patient 
in the knee-chest position, making traction on the cervix with a 
tenaculum and at the same time rocking the fundus upward by 
the promontory of the sacrum by pressure on the uterus through 
the abdomen. Often the Sims position is more favorable for this pro- 
cedure, and sometimes it will be necessary to pack the vagina with 
cotton tampons and make a second attempt after an interval of 
forty-eight hours. In my experience the administration of an 
anesthetic is seldom necessary. 

The Diagnosis of Interstitial Pregnancy and of Pregnancy in a 
Rudimentary Horn of a Bicornute Uterus. — In Chapter XIII., page 
198, are described the different sorts of anomalies of the uterus. 
E. Kehrer ("Das Nebenhorn des doppelten Uterus," 1899) col- 
lected eighty-two cases of pregnancy in rudimentary cornua. The 
diagnosis before operation in a majority of these cases lay between 
extra-uterine pregnancy, ovarian cyst and subserous myoma. 
The diagnosis of this condition intra vitam must always be 
considered extremely difficult. Kehrer cites five physicians who 
diagnosed the condition correctly and reports the cases in detail. 
The chief point of difference between tubal pregnancy and preg- 
nancy in the rudimentary horn of a uterus bicornis is that in the 
latter there is a thick pedicle or even no pedicle at all between the 
uterus and the gravid tumor, whereas in extra-uterine pregnancy 
there is a long slim pedicle, longer in ampullar and isthmial tubal 
pregnancy and shorter in interstitial tubal pregnancy. 

Interstitial 'pregnancy often simulates pregnancy in a rudimentary 
horn. The ovum developing in the uterine portion of the tube causes 
asymmetry of the uterus. Only when the conditions for examina- 
tion are most favorable can the separation between the pregnant 
horn and the main fundus uteri be felt. The sound may be passed 
into the main uterine cavity to prove that it is empty. I have 
seen two cases of interstitial pregnancy that became normal uterine 
pregnancies in the course of the third month as the fetus and its 
envelopes grew into the uterine cavity from the tube. As a rule 
the interstitial pregnant tumor is separated from the uterus by a 
shorter pedicle than the pregnant rudimentary horn of a double 
uterus. 

The Diagnosis That Pregnancy Has Occurred Previously. — In medi- 
colegal cases the physician may be called upon to give an opinion 

28 



434 ABNORMAL UTERINE PREGNANCY 

whether or no a woman has ever borne a child. The answer will 
depend upon the physical examination alone. Following preg- 
nancy the breasts are flabby and more or less pendulous, the 
changes in the nipples and areolae previously described are to be 
sought, also linese albicantes on the breasts or about the lower 
abdomen or hips. A scar from a mammary abscess is good evidence 
of previous lactation unless other satisfactory explanation of its 
presence is forthcoming. 

By vaginal examination the hymen will be found destroyed and 
in its place the carunculse myrtiformes, the vagina will show a 
certain amount of relaxation and absence of the rugae; lacerations 
of the perineum or pelvic floor are proof of previous pregnancy. 
The uterus will be found a little enlarged and the os will be found 
round, not the os tincse of virginity. A tear in the cervix is proof 
positive of child-bearing unless there is a history of instrumentation. 
Erosions with endocervicitis must not be mistaken for lacerations 
and their effects. 

The Diagnosis of Multiple Pregnancy. — The diagnosis of multiple 
pregnancy rests on rinding an unusually large uterus, a groove in 
the fundus separating the fetuses, hearing two fetal hearts, each 
with a different rhythm, and on the palpation of two heads or two 
breeches. 

The Diagnosis of Pernicious Vomiting of Pregnancy. — Excessive 
vomiting of 'pregnancy or hyperemesis gravidarum, occurring most 
frequently between the third and the fifth week of pregnancy, is 
of three varieties, according to J. Whitridge Williams, reflex, neu- 
rotic, and toxemic. In the reflex variety, the vomiting is apparently 
directly attributable to the existence of some abnormality of the 
generative tract such as retroflexion or anteflexion of the uterus, 
erosions or cicatrices of the cervix, or an ovarian tumor, and it 
ceases promptly upon the correction or removal of the abnormality. 
The fact, however, that in many pregnant women the presence of 
similar lesions is not associated with serious vomiting would ap- 
parently indicate that its reflex origin is quite exceptional, and is 
evidence that some other etiological factor is usually concerned in 
the production of the vomiting. The failure of suggestive treat- 
ment and the lack of evidence of serious changes in metabolism 
make it improbable that the affection is neurotic or toxemic in 
origin. 



PERNICIOUS VOMITING OF PREGNANCY 435 

In the neurotic variety the vomiting is dependent upon the 
existence of a neurosis — more or less clearly allied to hysteria — 
which may occur in women who had manifested no signs of im- 
paired nervous control previous to the occurrence of pregnancy. 
In such cases careful examination will fail to reveal the existence 
of a single physical condition which could account for the vomiting, 
while the most accurate chemical analysis of the urine will afford 
no evidence of serious metabolic disturbance; and, finally, char- 
acteristic lesions will not be found at autopsy in the rare cases 
which end fatally, as such patients die from starvation. 

Cure frequently follows the employment of apparently useless 
measures and unphysiological procedures, such as a vigorous 
lecture on the part of the physician, dilating the cervix, applying 
leeches to the epigastrium, or the administration of an anesthetic. 
A rigorous rest cure or suggestive treatment also may bring relief. 

Toxemic vomiting, on the other hand, is a very serious disease 
and is a manifestation of a profound disurbance in metabolism, of 
the exact origin of which we are ignorant. All that we know at 
present is that it usually ends in death, and sometimes leads to a 
fatal termination within a few days after the appearance of serious 
symptoms. In such cases the patient presents signs of a profound 
intoxication, and may die in coma without any evidence of star- 
vation. 

The urine, while diminished in amount as the result of the 
scanty intake of fluids, does not contain albumin or casts until 
shortly before death, and may apparently present a normal amount 
of urea, as determined by the Doremus method, so that its casual 
examination gives no clew to the gravity of the condition. 

In reality, however, there is a decided decrease in the amount 
of nitrogen excreted as urea and a marked increase in the amount 
put out as ammonia. Accordingly, while the total nitrogen output 
may be practically normal, the percentage of nitrogen eliminated 
as ammonia is greatly increased, and this so-called " ammonia 
coefficient," instead of being 4 or 5 per cent as in normal pregnancy, 
may rise to 20, 30, or 40 per cent. Moreover, the proportion of 
amido-acids is increased, and sometimes the acetone content is 
abnormally large. 

In making a differential diagnosis between the three varieties it 
is essential to eliminate the toxemic form by a careful urinary 



436 ABORTION 

analysis. If the ammonia coefficient exceeds 10 per cent the 
diagnosis of toxemic vomiting should be made. If the ammonia 
coefficient is approximately normal the probability of a serious 
toxemic condition can be eliminated and the diagnosis will be 
between the reflex and the neurotic varieties. Some manifest 
lesion in the generative tract makes the diagnosis reflex vomiting. 
The suggestion has been put forward by F. P. Underhill and R. 
F. Rand (Archiv. of Internal Medicine, Jan. 15, 1910, Vol. 5, p. 61), 
that the changes observed in the urine in pernicious vomiting of 
pregnancy are induced by the inanition which accompanies the 
severe grades of the disease and that the urine shows nothing 
characteristic until a stage of great prostration has been reached. 
They think that the supply of carbohydrates to the system is the 
factor which determines the relative output of urea and ammonia 
and claim good results in the treatment of pernicious vomiting 
by the administration by enema of dextrose in solution. 



THE DIAGNOSIS OF ABORTION 

Definitions. — An abortion is the expulsion from the uterus of the 
products of conception before the placenta is formed, that is, 
during the first three months; a miscarriage is the emptying of 
the uterus of the fetus, the placenta and its membranes, from the 
begining of the fourth month until the child is viable, at the end 
of six and three-fourths months; and a premature labor is the 
delivery of the child after it is viable, or between six and three- 
fourths months and term. 

The word abortion is so frequently used to mean the expulsion 
of the products of conception at any time from the beginning of 
pregnancy up to the time of viability that it is convenient to so 
use it in this chapter. 

A complete abortion is one in which the fetus and its membranes 
are cast off entire ; an incomplete abortion is one in which the fetus 
is born, but the membranes and the placenta, if formed, remain 
behind; a concealed or missed abortion is one in which the embryo 
has perished but is not expelled; spontaneous abortions are those 
which occur without known cause; induced abortions are those 
which are caused artificially and intentionally, whether by the 



ETIOLOGY 437 

administration of drugs or by the use of intruments, and habitual 
abortions are abortions repeated in successive pregnancies. 

Frequency. — Obviously exact figures as to the frequency of 
abortions are difficult to obtain. Without doubt many occur 
during the first six weeks of pregnancy without attracting much 
attention, and many patients who have abortions are not under a 
physician's care. J. Clifton Edgar found 635 cases of interruption 
of pregnancy — abortion, miscarriage, or premature delivery — 
among 10,000 cases of labor treated in a dispensary service in 
New York City, or one in every 15.7. Some authors give the 
frequency of abortions as once in every five or six cases of labor. 

Abortion proper is more apt to occur in multiparas, while mis- 
carriages and premature labors are found more commonly in 
primiparse. This seems to be due to the frequency of uterine 
disease in multipara?, so that with an increasing number of preg- 
nancies the uterus becomes progressively less tolerant and expels 
its contents earlier with each successive pregnancy. 

Etiology. — The causes of abortion may be grouped in three 
classes in the order of their frequency: (1) maternal, (2) fetal, 
and (3) paternal. 

1. The maternal causes are (a) constitutional and (b) local. 
a. Constitutional. Under this heading are to be classed the in- 
fectious diseases, as typhoid fever, pneumonia, smallpox, scarla- 
tina, cholera, especially if accompanied by high fever suddenly 
developed, and tuberculosis and syphilis. Syphilis in the mother 
is a very frequent cause of abortion, some authors going so far as 
to claim that it causes a quarter of all abortions. 

Other causes of abortion are cardiac diseases, the toxemia of 
chronic nephritis, diabetes mellitus, lead or arsenic poisoning, 
anemia from sudden loss of blood, the use of oxytoxic drugs, as 
ergot, cotton-root bark, quinine, aloes, and tansy, b. Local causes 
are all those conditions that cause pelvic congestion, such as 
malpositions of the uterus, especially retrodisplacements, chronic 
endometritis, lacerations of the cervix, and excessive sexual inter- 
course. 

2. The causes in the ovum and embryo are, anything that interferes 
with the nutrition or produces the death of the fetus. Many of 
them are secondary to pathological conditions in the mother's 
tissues. They are syphilis of the decidua or placenta, and low 



438 ABORTION 

situations of the placenta, also, less frequently, anomalies of the 
deciclua and the other fetal envelopes or of the fetus itself, pro- 
ducing injury or death. Introducing foreign bodies into the uterus, 
such as catheters or hatpins, must be reckoned as local causes. 
When the fetus is dead it acts like a foreign body and the uterus 
expels it. In exceptional instances the fetus may be retained in 
the uterus as long as two weeks after its death. 

3. The causes due to the father are chiefly syphilis transmitted by 
the spermatozoa. Sometimes there are syphilitic changes in the 
placenta and fetus where the mother shows no sign of the disease. 
Other causes are debility in the father, perhaps due to tuberculosis, 
perhaps to excessive indulgence in sexual intercourse. A French 
author has cited the instance of thirty cows who were served by 
the same bull within a short period of time. The fifteen that 
were served first went to full term, while the last fifteen aborted 
without an exception. 

Symptoms. — In abortion during the first six weeks there are 
seldom any prodromal symptoms. The woman may think she 
has a delayed and profuse menstruation, and may not realize that 
she is pregnant. Much blood is lost and clots are passed, and there 
may be pains in the region of the uterus. If she thinks she is 
pregnant and observes the clots she will think that she has seen 
the fetus in the " fleshy mass" that she has passed. The ovum, as 
a matter of fact, is generally passed first of all and is lost with the 
blood and clots. In the case of a complete abortion all of the 
embryo and its envelopes are passed at once and there is very 
little hemorrhage, the process lasting from twenty-four to forty- 
eight hours from the first hemorrhage or pain until all symptoms 
cease. Abortions are more apt to be incomplete, portions of decidua 
being left behind, and, in this event, hemorrhage continues. 

In abortion from the sixth to the twelfth week there are apt to 
be prodromal symptoms of fullness and weight in the pelvis and 
backache, indicating pelvic congestion. At this time uterine pains 
and hemorrhage are more severe and constitutional symptoms 
such as nausea, pallor, rigors, nervousness, and apprehension are 
often marked. After the third month the symptoms of abortion 
are more like those of labor at term. The three stages of labor 
can be distinguished, the uterine contractions are more marked, 
and there are strong involuntary bearing-down efforts. 



DIAGNOSIS 439 

Diagnosis. — The diagnosis of abortion depends on the deter- 
mination that the patient is pregnant; on the character of the pain, 
indicating uterine contractions; on the amount and character of 
the hemorrhage ; on dilatation of the cervix ; and on the descent of 
the products of conception into or through the os uteri. Practically 
we are called on to distinguish between threatened abortion, in- 
evitable abortion, and an abortion partially or wholly completed. 

The Diagnosis of Threatened Abortion. — First we get the history 
to determine the probability of the existence of pregnancy. If it 
can be learned that the patient has missed a catamenia twice or 
even once, if she has been exposed to impregnation, if she has 
experienced any disorders of digestion, or will tell of swelling of 
the breasts, or frequency of micturition, we may get valuable clews. 
Pain, if it indicates uterine contractions, is of a rhythmical char- 
acter, beginning in the flanks and extending to the pubic region. 
The distinct character of the pain is more clearly marked in mis- 
carriages than in abortions proper and in the threatened abortion 
there is little or no pain. Hemorrhage is moderate in amount, 
bright in color, free from clots, and intermittent. Examination 
shows breast changes (see section on normal uterine pregnancy, p. 
421), purplish discoloration of the vagina and cervix, the cervix 
soft, the os somewhat dilated. The uterus is enlarged, the fundus 
is bulging forward, the lower uterine segment is compressible, and 
uterine contractions are infrequent. 

If, after a series of hours, the symptoms abate and the cervical 
canal does not dilate, the ovum does not descend, and uterine con- 
tractions are still of infrequent occurrence, the case may be said 
to be in the category of a threatened abortion. 

The Diagnosis of Inevitable Abortion. — If, on the other hand, the 
hemorrhage increases in amount, is persistent, and contains clots 
and fragments of fetal structures, pain is considerable and increas- 
ing in severity, and local examination shows that the ovum has 
moved down in the uterus, as attested by the elimination of the 
angle of anteflexion between the large anterior fundus and the 
cervix, while the ovum can be felt by the tip of the examining 
finger through the dilated os as a soft bag, uterine contractions 
being frequent, the case is one of inevitable abortion. 

An ovum may be differentiated from a blood clot by noting 
that it increases in size during a uterine contraction, becomes 



440 ABORTION 

smooth and tense, and advances, while the blood clot is not tense 
and does not advance; also, the ovum presents a convex surface and 
is elastic, while the blood clot is cone-shaped with its apex down- 
ward and is not elastic. All clots or tissue passed should be floated 
out in water and examined with a magnifying glass for decidua, 
fringe-like chorionic tissue, or bits of placenta, the tissue being 
examined subsequently under the microscope. 

The Diagnosis of Abortion Partially or Wholly Completed. — To 
determine whether all or a part of the contents of the uterus have 
been expelled it is necessary to have everything which has been 
passed from the vulva preserved for careful inspection. To this 
end the napkins worn by the patient should be saved, and, before 
emptying the bladder or bowels she should sit on a chamber and 
strain so that the contents of the vagina may be expelled into 
the chamber for preservation. The ovum, being small and sus- 
pended in the liquor amnii, is usually lost when the membranes are 
ruptured early in the course of an abortion, being passed from the 
vagina at stool. Parts of the decidua are more often left in the 
uterus than not. In very early abortions the pieces of tissue can 
be felt with the tip of the uterine sound palpating the uterine 
cavity. When there is any foreign substance in the uterus the 
cervical canal will be found open. In pregnancy exceeding three 
months' duration the finger can be passed into the uterine cavity and 
will feel the bits of fetal membranes or portions of placenta still ad- 
herent to the walls. The Emmett curette forceps will bring away 
tissue for examination. If the tissues appear to be in any respect 
abnormal they should be sent to the pathologist for examination. 
The finding of an intact ovum settles the question of a complete 
abortion. The disappearance of the secretion of the breasts is an 
important sign that an abortion is complete. If the abortion is 
completed the uterus will be found contracted and the uterine canal 
closed. In missed abortion the dead fetus may be retained in the 
uterus for some time; there are no pain and no hemorrhage, but 
the cervix remains soft and the os patulous. 

The Diagnosis of Miscarriage. — The diagnosis of miscarriage is 
generally easier than that of abortion because the signs of pregnancy 
are definite and pronounced and the same may be said of the 
symptoms (see the diagnosis of normal uterine pregnancy, page 426). 

Differential Diagnosis.— Abortion must be differentiated from 



HYDATIDIFORM MOLE 441 

extra-uterine pregnancy and from menorrhagia, metrorrhagia, 
and dysmenorrhea. In abortion the hemorrhage is generally 
greater in amount and the clots are more frequently passed than 
in early extra-uterine pregnancy after rupture; the pain is much 
less severe in abortion and is of the uterine contracture variety, 
that is, beginning as an aching in the flanks and radiating to the 
hypogastrium, whereas in extra-uterine pregnancy the pain is 
severe, agonizing, and in the beginning is unilateral. The changes 
in the uterus are more marked in abortion than in extra-uterine 
pregnancy, and in the latter some tumor of the adnexa can be 
determined. It is to be remembered that a uterine decidua is 
formed in the case of extra-uterine pregnancy and this is apt to be 
passed early. 

Menorrhagia and metrorrhagia are excluded by the history, 
which excludes pregnancy, and by the absence of the symptoms 
and signs of pregnancy, also by determining some cause for the 
increased flowing, such as a fibroid tumor, endometritis, or cancer. 
Dysmenorrhea is excluded by the past history of pain occurring at 
some definite interval of time before, after, or during the flow, and 
by the absence of the symptoms and signs of pregnancy. 



THE DIAGNOSIS OF HYDATIDIFORM MOLE 

Hyclatidiform mole, also called vesicular or cystic mole, is a dis- 
ease of the chorion consisting of a cystic formation at the ends of 
the villi, producing a mass that resembles a bunch of grapes. It is 
a rare disease occurring once in about three thousand cases of preg- 
nancy and is found oftenest among multipara between the ages of 
twenty-five and forty. It is apt to be repeated in successive preg- 
nancies in the same patient. The mole generally develops before 
the fourth month and causes the death of the fetus. 

Pathology. — The cystic process which involves the chorion 
is, according to Marchand, an edematous degeneration in which 
the syncytium plays an important role. Large masses of syncy- 
tium and chorionic epithelium invade the decidua and the 
uterine walls just as in chorio-epithelioma, the process resembling 
this disease which follows hydatidiform mole in about half the 
cases. The translucent vesicles are similar in shape to the elements 



442 HYDATIDIFORM MOLE 

of the chorion of the first two months, being fusiform, pyriform, 
or rounded, they contain a fluid that is similar to liquor amnii, and 
of the chorion of the first two months, being fusiform, pyriform, 
they range in size from a pin's head to a large grape. The mass of 
vesicles may grow to the size of a man's head, the myxomatous 
degeneration involving the entire surface of the chorion, or it may 




Fig. 182.— Hydatidiform Mole. (Bumm.) 

be a small tumor involving only the placental portion of the chorion. 
The mass is expelled by the uterus as a rule in the fourth or fifth 
month with labor pains and hemorrhage, but portions of the cystic 
mass are apt to be closely adherent to the uterine wall so that 
some is apt to be left behind, necessitating a curetting. The fetus 
may be destroyed in cases of extensive disease, or it may be pre- 



DIAGNOSIS 443 

served in cases of minor involvement. It is generally killed early. 
Sometimes, when the uterine blood-vessels are eroded, the hemor- 
rhage from hydatidiform mole may be excessive. 

Symptoms. — In the first few weeks of pregnancy there is no 
means of distinguishing cystic disease of the chorion. As the 
pregnancy advances the uterus containing hydatidiform mole 
increases in size more rapidly than in the case of normal pregnancy, 
and hemorrhage occurs with a bloody, watery discharge, which is 
not unlike currant-juice in appearance. 

Diagnosis. — The diagnosis rests on the symptoms and on a 
doughy feeling of the uterus on bimanual palpation, this being 
demonstrable after the third month when the rapid growth of the 
uterus becomes apparent. If the cysts are found in the vaginal 
discharge the diagnosis is certain. No fetal movements or heart 
sounds are heard and there is no ballottement. 

The possibility of the development of chorio-epithelioma follow- 
ing hydatidiform mole should never be lost sight of, and every 
patient should be kept under close observation for at least a month 
after the expulsion of the mole. 



CHAPTER XXIII 
THE DIAGNOSIS OF DISEASES OF THE URETHRA 

Anomalies, p. 444: Persistent urogenital sinus, p. 444. Hypospadias, 
p. 444. Partial defect of the external urethra, p. 444. Epispadias, p. 445. 
Atresia of the urethra, p. 445. 

Displacements of the urethra and alterations in form, p. 445: Upward 
dislocation, p. 445. Downward dislocation, p. 446: Diagnosis, p. 446; 
Differential diagnosis, p. 447, Urethrocele, p. 447. Suburethral abscess, 
p. 447, Dilatation of the urethra, p. 447, Dangers attending dilatation, p. 
447, Prolapse of the urethral mucosa, p. 448. 

Inflammation of the Urethra, Urethritis, p. 450: Acute urethritis, p. 450. 
Chronic urethritis; (a) Diffuse; (b) Circumscribed, p. 451: Latent 
gonorrhea, p. 452. 

Stricture of the urethra, p. 451. 

New growths of the urethra, p. 453: Urethral caruncle, p. 453. Polypus 
of the urethra, p. 455. Primary Cancer of the urethra, p. 455. Sarcoma of 
the urethra, p. 456. 

The anatomy of the urethra and the methods of examination 
and the technique of endoscopy will be found in Chapter VIII., 
page 100. 

ANOMALIES 

The congenital defects of the urethra are: absence of the 
urethra, hypospadias, dilated short urethra, epispadias, and 
atresia. The development of the urethra and bladder is shown in 
the diagrams from Schroeder in Chapter XXL, page 395. Where 
the urethra has failed entirely to develop the bladder opens directly 
into the vagina, and the case may be regarded as a persistent 
urogenital sinus. Several of these cases have been reported in the 
literature, but more common are the instances of lack of develop- 
ment of the lower portion of the urethra. If the part lacking is the 
posterior urethral wall the case is one of hypospadias, and if both 
anterior and posterior walls are absent in the lower course of the 
urethra it is a case of partial defect of the external urethra. In cases 
of absence of the vagina the urethra is commonly found dilated 
and short, in some cases being of large enough caliber to admit 

444 



DISPLACEMENTS OF THE URETHRA 445 

the penis. Many authors have assumed that the large size of the 
urethra in such patients is due to forcible dilatation during coitus, 
but as the large urethra is found in unmarried women who are 
the subjects of absence of the vagina — in patients who could 
never have been subjected to sexual intercourse — the condition 
of the urethra must be regarded as due to a partial persistence of 
the urogenital sinus. Intercourse has undoubtedly taken place 
through such a urethra in many instances, but we must not regard 
the dilatation by the penis as the primary cause of the large 
caliber. 

Epispadias is a defect of the upper wall of the urethra associated 
with separation of the labia minora and division of the clitoris. 
In extreme cases of epispadias there is also exstrophy of the bladder 
together with deficiency of the anterior bladder wall. The con- 
dition is rare, as is atresia of the urethra, which is supposed to be 
due to inflammatory affections late in intra-uterine life causing 
more or less complete occlusion of the urethral canal. There must 
be some avenue of escape for the urine even before birth or else 
the child has great distention of the abdomen from overfilled 
bladder, ureters, and kidneys. Partial atresia may be relieved 
soon after birth by passing a sound, as in the case reported by 
Mandl and cited by Kelly, in which a child two days old had vom- 
iting and convulsions until the atresia of the urethra was broken 
down by a sound. 



DISPLACEMENTS OF THE URETHRA AND ALTERATIONS 

IN FORM 

Upward Dislocation of the Urethra 

Upward dislocation of the urethra may occur from dragging on 
the bladder and the urethra in the case of large tumors and in 
pregnancy. It is supposed that the traction on the neck of the 
bladder may be the cause of frequency of urination, which some- 
times occurs in these cases; more often there are no symptoms 
at all. Rarely there is retention of urine, and the catheter, 
when passed, traverses a long route up behind the pubic bone. 
A soft rubber catheter is safer than a glass or silver one in such 
cases. 



446 DISEASES OF THE URETHRA 

Downward Dislocation of the Urethra 

Downward dislocation of the urethra is a fairly common lesion 
resulting from child-birth. The entire urethra may be torn from 
its pubic supports, as in the case of procidentia, or only the upper 
portion may be freed from its fastenings. Not infrequently 
careful examination will reveal dislocation of the upper third of 
the urethra in cases where prolapse of the uterus is not present. 
We must suppose that in these cases the uterus and its ligaments 
have involuted and regained a normal state, while the sundered 
tissues under the pubic arch are unable to support the urethra 
in a normal situation. Downward dislocation of the urethra 
may be attended by no symptoms, or the patient may experience 
sudden stoppage of the urine during urination, or there may be 
partial incontinence. The tone of a dislocated urethra is apt to 
be below par, therefore such a urethra is more likely to become in- 
fected than is a normal one. 

Diagnosis. — The diagnosis is established by palpation of the 
urethra with a sound in its canal and a finger in the vagina, also 
by inspection of the vagina while the sound passes through the 
urethra, the patient being in the dorsal position. For this purpose 
employ a sound that is about three-sixteenths of an inch in diam- 
eter or a Kelly urethral dilator of the same caliber (4 millimeters) 
so that this larger sound may occupy the entire lumen of the 
urethra, and thus indicate the true course of the organ, and not 
— as would be the case with a small sound — enter a diverticulum, 
if present. With this sound passed so that its tip is just below the 
neck of the bladder, tilt the point downward and note whether the 
urethra is held to the os pubis or goes downward into the vagina. 
Next substitute a uterine sound for the dilator, bend the terminal 
inch of the sound to an angle of thirty degrees, and introduce it with 
the point downward. If the upper third of the urethra is dislocated 
downward the point of the sound, following the course of the 
displaced urethra, may be seen and felt in the vagina. 

In my private case records are the notes of fifteen cases of down- 
ward dislocation of the urethra not associated with uterine prolapse. 
In cases of uterine prolapse with accompanying dislocation of 
bladder and urethra, the course of the urethra in the prolapsed 
mass is mapped out with the bent sound in the urethra. 



DISPLACEMENTS OF THE URETHRA 447 

Differential Diagnosis. — We must differentiate urethrocele, which 
is a pocket in the lower wall of the urethra — generally in the 
middle third of its course — from downward dislocation of the 
urethra. This is done by noting the general course of the urethra 
by means of a large sound or Kelly dilator passed to the neck of 
the bladder. Withdraw the sound and pass a bent probe through 
the opening in the urethral wall into the urethrocele, following the 
point of the probe with a finger in the vagina. Next pass a cysto- 
scope into the urethra and see the opening into the urethrocele, 
passing a probe through the cystoscope into the urethrocele to 
verify the diagnosis. Urine may collect in a urethrocele, decom- 
pose, and set up a urethritis. The urine is ejected during the act 
of coughing, laughing, or straining, and the patient complains of 
this sort of incontinence. 

Dislocation of the urethra downward must be differentiated 
from suburethral abscess, an abscess occupying the urethro- vaginal 
septum, varying in size from a cherry to a hen's egg. Such an 
abscess has a chronic course and is supposed to originate in Skene's 
glands, in a diverticulum from the urethral canal, or in a suppurat- 
ing cyst of the urethro- vaginal septum. It is the seat of pain and 
soreness during urination, defecation, and coitus,, the latter often 
being impossible of accomplishment because of the tenderness of 
the vagina. The abscess generally opens into the urethra by a 
minute opening, and pressure on it through the vaginal wall causes 
the sac to collapse as it is emptied. In some cases the patient 
experiences periodic discharges of pus from the urethra. If the 
cystoscope is passed up to the vesical neck and withdrawn, a few 
drops of pus will be seen to gush into its lumen after the tip of the 
cystoscope has passed the opening into the abscess. A probe 
passed into the opening and palpated per vaginam establishes 
the diagnosis. 

Dilatation of the Urethra. — Congenital enlargement of the urethra 
has been referred to in discussing the anomalies as a manifestation 
of the persistence of a urogenital sinus. Stricture or tumor of 
the urethra if situated near the meatus may cause dilatation of the 
urethra behind the stricture or tumor. 

All of the structures of the urethra are hypertrophicd during 
pregnancy and Skene thought that the urethra was dilated at 
that time. Artificial dilatation has been caused by coitus per 



448 DISEASES OF THE URETHRA 

urethram and by introducing foreign bodies into the urethra for 
purposes of masturbation, and, also, dilatation of the urethra was 
formerly practiced by physicians for the purpose of digital ex- 
ploration of the bladder for suspected stone or tumors of that organ. 
The urethra is extremely tolerant of dilatation and bladder stones 
as large as an inch in diameter have been passed spontaneously 
through the urethra, followed by only temporary incontinence. 
Nevertheless, forcible dilatation of the urethra to a diameter of 
more than half an inch (12 millimeters) is entirely unjustifiable, 
because permanent incontinence is very apt to be the result. Few 
physicians possess a forefinger whose knuckle at the end of the 
first phalanx measures less than three-quarters of an inch (18 
millimeters) in diameter and most forefingers are much larger. 
The interior of the bladder can not be palpated unless this knuckle 
is passed into the urethra. Examination with the little finger is 
inadequate, although the lower portions of the bladder may be 
reached with its tip. Modern methods of cystoscopy do away 
with the need of digital exploration and we may subscribe to Dr. 
Thomas Addis Emmet's vigorous statement to his students in the 
old days at the Woman's Hospital, that the man who dilates a 
woman's urethra with his ringer should be put in jail. 

The diagnosis of a dilated urethra is made by observing pouting 
of the meatus, and a distinct ridge in the vagina corresponding 
to the course of the urethra. By touch per vaginam the enlarged 
urethra may be felt as an elastic, rolled-up, membranous tube, 
and on introducing a large Kelly dilator into the urethra, it slips 
easily into the bladder. Moving the tip of a uterine sound about 
in the urethra we determine an enlarged canal, and by palpating 
the sound per vaginam we learn the thickness of the tissues of the 
urethro- vaginal septum. The No. 12 cystoscope passes easily, 
and the larger sizes of the urethral dilators introduced successively 
will tell of the exact diameter of the urethra. 

Prolapse of the Urethral Mucosa. — This rare affection consists 
of an eversion or turning out of the urethral mucous membrane 
through the meatus. For some reason the hypertrophied mucosa 
becomes loosened from its attachments and is extruded from the 
external orifice in the shape of a deep red or bluish tumor with 
the orifice of the urethra in its center. The extreme grade of this 
affection is most often found in debilitated old women and in 



DISPLACEMENTS OF THE URETHRA 



449 



young children; a moderate amount of eversion may occur in any 
woman who has had children. In the pronounced grades the 
prolapsed mucous membrane may become edematous or even 
gangrenous. The diagnosis is made by discovering a deep red 
tumor in the situation of the vestibule, that is covered everywhere 
with easily bleeding mucous membrane, and has a slit in its 
center that gives access to the bladder. If only a portion of 





o 



Fig. 183. — Prolapse of the Urethral Mucous Membrane. (Montgomery.) 

the circumference of the urethra is involved in the prolapse the 
everted mucosa may be mistaken for a polypus, a urethral caruncle, 
or eversion of the bladder mucosa. If the prolapsed mucous mem- 
brane is seized with a delicate pair of forceps and drawn down it 
will be found to have a broad base and will be increased in size; 
in the case of a polypus or caruncle drawing the tumor down will 

show a pedicle, and no increase in size beyond the elongation due 
29 



450 DISEASES OF THE URETHRA 

to traction. In many cases the everted mucosa may be replaced 
in the urethra by the use of cocaine and taxis. 

If the case is one of eversion of the mucosa of the bladder, the 
sound passed into the urethra can be made to sweep entirely around 
the tumor, and when passed further there is no bladder cavity to 
receive it. By taxis and pressure with a large-sized sound the 
prolapsed mucous membrane may be pushed into the bladder. 
Cystoscopy will show the distended bladder and the portion of 
the lining that had been prolapsed to be of a deep red color. 



INFLAMMATION OF THE URETHRA: URETHRITIS 

Urethritis is a common affection in women, though not so often 
diagnosed as in the male; " irritable bladder" and " cystitis," in 
the place of an exact diagnosis, often meaning urethritis. With 
the more general use of the endoscope we are learning more of 
this disease. It is most often due to the gonococcus, but may be 
due to an extension downward of a cystitis, to traumatism — as 
from injuries during childbirth or from the passage of a calculus — 
to urethral new growths, or to an extension upward of a vulvitis. 
The disease is limited to the mucous and submucous tissues, which 
are injected, swollen, and secrete pus; the upper and lower portions 
of the urethra being more often affected than the middle part. 
Urethritis occurs in two forms, acute urethritis, and chronic ure- 
thritis, the inflammatory process having a marked tendency to 
lurk in Skene's glands. This is true especially of the gonococcus 
form, which may be cured apparently, only to be lighted up anew 
into an acute attack when the gonococci have found fresh culture 
material in another individual. 

Acute Urethritis. — Acute urethritis begins with burning and 
itching in the neighborhood of the urethra, followed in one or two 
days by painful micturition. The body temperature may be 
elevated and anorexia and lack of energy may be present for a 
short time. The patient notices that her linen is discolored by a 
purulent discharge and even by blood; for there may be bleeding 
in the most acute stage. The local examination should be made 
before the patient has urinated. The dorsal position is used. A 
drop of pus appears in the meatus and the mucosa at the orifice 



URETHRITIS 451 

of the urethra is injected, red, and swollen. Stroking the urethra 
from above downward by a ringer in the vagina, pus issues from 
the orifice of the urethra. If it does not come from the urethra 
it may be expressed from the openings of the canals of Skene's 
glands, which are situated one on each side in the lower portion 
of the labia urethrse just inside the meatus. The finger in the 
vagina notes increased body heat and tenderness of the urethra. 
In this acute stage it is just as well not to use the endoscope be- 
cause of the damage it must inflict on the inflamed mucosa. If it 
is used with the aid of a strong solution of cocaine, the mucous 
membrane is seen to be bright red and bleeding easily and pus 
issues from between the folds and from the minute glands, or there 
are to be seen linear ulcers two to four millimeters long and one 
millimeter broad, generally on the posterior wall. Great care 
should be exercised not to introduce the endoscope (Kelly Cysto- 
scope No. 8) beyond the bladder neck, for fear of infecting the 
bladder. Smears should be made and examined for the gonococcus. 
Concomitant inflammation of one or both of Bartholin's glands 
indicates probable gonococcus infection. 

Chronic Urethritis. — Chronic urethritis is the form of urethral 
inflammation most often seen by the gynecologist. It commonly 
follows acute urethritis, although the latter may have given very 
few symptoms and may not have been diagnosed. 

The disease is diffuse or circumscribed. 

(a) Diffuse Chronic Urethritis. — This generally follows acute 
urethritis. The longer the inflammatory process has existed the 
paler becomes the mucosa and the greater the thickening of the 
mucous and submucous tissues because of new formation of con- 
nective tissue. In the later stages of chronic urethritis the urethra 
is felt as a hard tube, only moderately tender to touch. The symp- 
toms may be nothing more than itching or burning in the region 
of the urethra and perhaps frequency of micturition. There is some 
swelling and a gelatinous and granular condition of the mucosa 
at the external orifice. The mucosa pouts out into the lumen 
of the endoscope so that the canal appears closed; it is dull red in 
color, granular and soft, and the lacuna?, crypts, and openings of 
the glands show as deeper red spots, perhaps giving exit to pus. 
The disease is most often met with in prostitutes. 

(b) Circumscribed Chronic Urethritis. — In this form one sees 



452 DISEASES OF THE URETHRA 

through the cystoscope patches of pale, almost gray mucous mem- 
brane surrounded by the pale red, normal mucosa. Later the 
pale areas become whiter still as they represent scar tissue, and 
they sometimes form strictures of the urethra. When the specu- 
lum is passed through such cicatricial areas they show decreased 
elasticity and tear easily, causing bleeding. The chronic inflam- 
mation may be limited to the region of Skene's glands. In this 
case there will be reddening about the orifices of the ducts of the 
glands and pressure through the vagina will express a drop of pus 
or turbid serum from the gland. The discharge is apt to be thin 
and serous in the chronic cases, and gonococci are few. Careful 
search for this organism should be made. Skene's glands are 
among the chief lurking places of latent gonorrhea, the other most 
frequent situations being the cervical canal and Bartholin's glands. 
If the gonococcus can be isolated from the discharge from either 
of the latter organs, even though it is absent in the urethral dis- 
charge, the inference is that gonococcus infection of the urethra 
is present also. Several microscopic examinations should be made 
from the discharges from each of the three situations before pro- 
nouncing that gonorrhea is absent. 



STRICTURE OF THE URETHRA 

Van de Warker as long ago as 1887 called attention to the fre- 
quency and importance of strictures of large caliber in women. My 
own experience has taught me that such strictures are relatively 
frequent and are found by the physician who does a good deal of 
cystoscopic work. In my private records are the notes of nine cases 
that I have seen, and Pasteau (quoted by Knorr) saw twelve cases 
and had collected one hundred and twelve from the literature. 

Strictures are caused by chronic gonorrheal urethritis, by in- 
juries of the urethra during labor, by cicatricial contracture of the 
anterior vaginal wall, due to a slough, or very rarely to cicatriza- 
tion of a chancre, or carcinoma of the urethra. Stricture at the 
meatus sometimes results from kraurosis vulva?. 

The symptoms of stricture are : painful and difficult micturition, 
the urine being passed in a small stream. A small meatus is very 
commonly met with in women and is diagnosed by passing the 



NEW GROWTHS OF THE URETHRA 453 

conical calibrator. Any measurement in the adult under 6 milli- 
meters must be classed as small. A stricture is detected by passing 
the graduated urethral dilators and noting the situation and size 
of the point of resistance. Through the cystoscope one sees irreg- 
ular rolling-in of the mucosa and asymmetry, the strictured portion 
being whiter than the surrounding mucosa, non-elastic, and bleeding 
if stretched. 



NEW GROWTHS OF THE URETHRA 

The new growths observed as occurring in the urethra are car- 
uncle, polypi, cancer, and sarcoma. 

Urethral Caruncle. — Urethral caruncle is the term used to denote 
a highly vascular tumor which projects from the urinary meatus. 
It is a common affection. Lange has described three forms ac- 
cording to their pathology; (a) granuloma, (b) papillary angioma, 
and (c) telangiectatic non-papillary mucous polyp. 

a. The granuloma is characterized by infiltration of round cells 
and abundant capillaries, and is the result of a gonorrheal lesion of 
the urethra, b. Papillary angioma is a highly vascular mucous 
polyp. It has a covering of pavement epithelium with nipple-like 
elevations, and is invaded by connective-tissue elements, c. The 
telangiectatic variety is characterized by an abundance of thin- 
walled capillaries, these being so dilated often as to give the tissue 
a cavernous character; they may even contain cysts. This tumor 
has no papillae. 

All three varieties are found with equal frequency in middle life, 
the granuloma is more often found in young women between twenty 
and forty, and the papilloma variety in women over forty. As a 
rule, urethral caruncle is observed late in the childbearing period 
of life, although it may be found at any age from childhood to old 
age. The symptoms are excessive pain on urination and sensitive- 
ness of the vulva, even to the slightest touch, also frequency of 
micturition and derangement of the nervous system. Patients 
may hold their urine for long periods of time to avoid the pain 
experienced on passing it. Pains, which we may call sympathetic, 
radiate in all directions from the pelvis, just as in vaginismus. 
One of my patients complained of a spasmodic drawing up of one 



454 



DISEASES OF THE URETHRA 



thigh so that when she walked one leg seemed shorter than the 
other. Physical examination showed no difference in the length 
of the limbs and no abnormality in the locomotor apparatus. 
The symptom was entirely done away with by the removal of the 
caruncle. Coitus is painful or impossible. The patient with a 
caruncle is apt to be morose, depressed, anxious, or even hysterical. 
The diagnosis is established by the appearances. On separating 




Fig. 184. — Urethral Caruncle. (Montgomery.) 

the labia one sees a brilliant red growth projecting from the meatus. 
It may look like a cock's comb or a very small raspberry and varies 
in size from a BB shot to a cherry, — large ones being unusual. 
Its surface is generally smooth, but may be roughened like the 
surface of a raspberry. The growth generally springs from the 
posterior wall of the urethra just inside the meatus and is either 
pedunculated or sessile. With a few exceptions urethral caruncle 



NEW GROWTHS OF THE URETHRA 455 

is exquisitely sensitive; now and then a non-sensitive tumor is 
seen. It bleeds easily, but does not, as a rule, bleed enough to 
soil the patient's linen, but a purulent vaginal discharge is a common 
accompaniment of these growths, perhaps because they are fre- 
quently of gonorrheal origin. They are of slow growth and almost 
always recur when removed unless every bit of tumor tissue has 
been taken out ; but the recurrent growth is like the first, and there 
is no tendency to malignancy or to extension beyond the original 
site. A thorough diagnosis can not be made often without cocaine 
or an anesthetic. The meatus must be dilated with the conical cali- 
brator and the exact situation and extent of the base of the tumor 
determined by the aid of the cystoscope. 

Polypus of the Urethra. — Certain forms of caruncle are polypi, 
as already stated in the consideration of caruncle. Mucous polypi 
situated in the middle and upper urethra are very rare. They 
cause few symptoms and are to be seen through the endoscope. 
A few cases of fibroma of the urethra have been described and 
one or two cases of myoma. 

Primary Cancer of the Urethra. — This is a rare disease, there being 
on record in 1903 only nine authentic cases. Secondary cancer 
of the urethra, on the other hand, is not so uncommon. The 
primary disease is a disease of older women and seems to start in 
the tissues about the lower urethra more often than in the urethra 
itself and to invade the mucous membrane late. Strictly speaking, 
only the form of cancer beginning in the urethral tissues should 
be classed as cancer of the urethra, but after the mucous membrane 
has been destroyed the differentiation of the primary point of 
origin is necessarily difficult. The disease must be differentiated 
from caruncle, chancre, and tuberculosis. In caruncle the tumor 
is soft and does not increase in size; it is situated in the urethral 
canal, generally on the posterior wall. In the case of primary cancer 
the growth is hard and is seldom seen before it has involved a 
wide area. The ulcer of a chancre follows a suspicious intercourse 
with a definite period of incubation, twenty-six days. It heals in 
a short time, leaving a scar. The ulceration of cancer is of long 
duration, it extends to the surrounding parts, and the history of 
infection is absent. Perhaps the Spirochseta pallida can be isolated 
from the discharge. In the case of a tuberculous ulcer the cheesy 
matter and the tubercles, characteristic of tuberculosis, may be 



456 DISEASES OF THE URETHRA 

seen by the naked eye, and there is little or no induration of the 
base of the ulcer as in the case of both cancer and chancre. In all 
doubtful cases a piece of tissue should be excised for microscopic 
examination. 

Sarcoma of the Urethra. — This is a very rare disease, only four 
cases having been reported. Three of the cases were in women 
fifty years of age or older, and the fourth in a child of three. The 
symptoms are bleeding and the presence of a tumor in the situation 
of the urethra. The tumor is to be removed and examined under 
the microscope. 



CHAPTER XXIV 
THE DIAGNOSIS OF DISEASES OF THE BLADDER 

Anomalies, p. 457: Absence of the bladder, p. 457. Double bladder, p. 
458. Loculate bladder, p. 458. Epispadias and exstrophy of the bladder, 
p. 459. 

Alterations in form, and displacements, p. 459: Distended bladder, p. 459. 
Rupture of the bladder, p. 460. Contraction of the bladder, p. 461. Up- 
ward displacement, p. 461. Downward displacement, p. 461. Lateral 
displacement, p. 462. Hernia of the bladder, p. 462. Eversion of the 
bladder, p. 462. 

Foreign Bodies in the bladder, p. 462 : Calculi, p. 462. Other foreign 
bodies, p. 463. 

Cystitis, p. 465: Classification, p. 466: Etiology and pathology, p. 466: 
Catarrhal cystitis, p. 467; Ulcerative cystitis, p. 468; Exfoliative cystitis, 
p. 468; Tuberculous cystitis, p. 468. Certain rare forms of cystitis, p. 470. 
Symptoms of cystitis, p. 471. Diagnosis of cystitis, p. 471. 

Varix of the bladder, p. 474. 

Fistulas of the bladder, p. 474: (1) Vesico-vaginal fistula, p. 474; Fre- 
quency, etiology and pathology, p. 474; Symptoms, p. 476; Diagnosis, p. 
477: Differential Diagnosis, p. 478. (2) Vesico-uterine fistula, p. 479; Vesico- 
uterovaginal fistula, p. 479. (3) Vesico-intestinal and other fistula?, p. 479. 

New Growths of the bladder, p. 480: Symptoms, p. 481. Diagnosis, p. 
481. Benign tumors, p. 482; Papilloma, p. 482; Fibroma and Myoma, 
p. 483; Adenoma, p. 483. Malignant tumors, p. 483 : Carcinoma, p. 483; 
Sarcoma, p. 484. 

Functional Disturbances of the bladder, p. 485. 

The anatomy and technique of examination of the bladder 
have been described in Chapter VIII. , page 107. 

The diagnosis of diseases of the bladder is made by study of the 
history, by analysis of the urine, and by direct examination of the 
organ by means of palpation of its exterior and by inspection of 
its illuminated interior. 

ANOMALIES 

Absence of the bladder is a very rare malformation and is generally 
associated with a non-viable child. In these cases the ureters 
terminate in the urethra, the rectum, or the vagina. 

457 



458 DISEASES OF THE BLADDER 

Double bladder is another very rare malformation, which is apt 
to be associated with duplication of the other pelvic organs, as in 
a case reported by Suppinger, in which there was a double bladder 
and also double urethra, clitoris, hymen, and anus, each half of 
the pelvis containing a uterus unicornis, an ovary, and a tube. 

Loculate bladder, or a bladder presenting congenital pockets or 
diverticula which project outward from the main cavity of the 
bladder, is not so rare, and the same may be said of a bladder 
partially divided by a median septum. The congenital loculate 
bladder is not to be confused with the bladder pocketed by calculi 
or by inflammatory disease, neither is it to be classed as an instance 




Fig. 185. — The Base of the Bladder showing Diverticula. (Knorr.) 

of supernumerary bladders or double bladder, already mentioned. 
The diagnosis is established by observing the loculi through the 
cystoscope and noting that they are separated by ridges of mucous 
membrane, and not by scar tissue, the latter being hard and white, 
and the former soft and pink. 

A. L. Chute (Boston Medical and Surgical Journal, March 22, 
1906, p. 309) has called attention to a case in which a diverticulum 
of the bladder existed as the result of a previous suprapubic 
cystotomy, the pocket acting as a storehouse for organisms that 
had periodically reinfected the bladder. In the same paper he 
mentions a congenital diverticulum, diagnosed by the cystoscope, 
that acted apparently in the same way. 



ANOMALIES AND DISPLACEMENTS 459 

Hypospadias, a condition of persistent urogenital sinus, has 
been referred to under diseases of the urethra. 

Epispadias and exstrophy of the bladder are rarer in the female 
than in the male and are very seldom met. There is a failure of 
development in early fetal life both of the anterior wall of the 
bladder and of the anterior abdominal wall over the bladder, and 
if the entire front wall of the bladder is wanting, the symphysis 
pubis is absent also. The posterior wall of the bladder appears as 
a bleeding, reddened, rounded mass where the symphysis should 
be, just above the orifice of the vagina, and in its surface the 
openings of the ureters can be seen spurting urine from time to time. 
The surface of the everted bladder wall is covered with mucus 
and urine, and the odor of decomposed urine is strong. The urethra 
is generally wanting in these cases, the clitoris is fissured, and the 
vagina and uterus are apt to be undeveloped, although several 
cases of pregnancy occurring in the subjects of exstrophy of the 
bladder have been reported. Many of these malformed individuals 
die in early childhood. Excoriations and ulcerations of the skin 
surrounding the ectropion are generally present because of the 
constant escape of urine, and infection of the ureters and kidneys 
is a common complication. The general health is impaired on 
account of the local discomfort, the complications, and the inability 
to perform the ordinary duties of life. 



ALTERATIONS IN FORM, AND DISPLACEMENTS 

Distended Bladder. — The shape of the distended bladder in the 
woman is determined by its surroundings. The uterus and broad 
ligaments behind limit its excursion in that direction, therefore 
its greatest diameter when moderately distended is not longi- 
tudinal, as in the male, but transverse. In extreme distention 
when the vault rises into the abdomen the long diameter is on a 
line drawn from the base of the bladder to the umbilicus. A dis- 
tended bladder of this sort resembles an ovarian tumor rising from 
the pelvis. (See Fig. 84a, page 217.) Percussion of the anterior 
abdomen for a distance of a hand's breadth, more or less, above 
the symphysis, elicits a flat note, and fluctuation may be deter- 
mined by bimanual palpation. The catheter must be passed in 



460 DISEASES OF THE BLADDER 

all doubtful cases, and especially is this precaution necessary if 
there is a history of dribbling of urine. In the case of the overfilled 
bladder the desire to urinate ceases when the distention becomes 
extreme and the repeated involuntary loss of small quantities of 
urine may be the only symptom. If the bladder is very much 
distended the distress and pain in the lower abdomen which ac- 
company the earlier stages of distention may be absent. Patients, 
strange as it may seem, are very apt not to realize that the bladder 
has not been emptied and to give the physician the impression 
that they have been passing their urine, only, perhaps, too fre- 
quently. 

Rupture of the bladder may occur either by violence from with- 
out, as from blows or falls when the bladder is distended, or 
from excessive muscular efforts on the part of the patient 
herself, as in labor, or in the struggles of anesthesia. Rupture 
is more likely to occur if the bladder wall has been thinned by 
ulceration and sloughing, as well as by distention. It has been 
known to occur in extra-uterine pregnancy as well as from all sorts 
of trauma. 

One of the most frequent causes seems to be retroversion of the 
pregnant uterus. Krukenberg and Rivington collected between 
them the reports of twenty cases of this sort. Krukenberg thinks 
that in cases of retroversion and incarceration of the pregnant ute- 
rus the physician should proceed with great caution in replacing the 
uterus, and if portions of gangrenous bladder wall have been passed 
per urethram, abortion should be performed rather than replace- 
ment, because of the danger of rupturing the bladder during the 
necessary manipulations. Rupture is commonly intra-peritoneal 
and uncommonly extra-peritoneal. The diagnosis of rupture de- 
pends on sudden abdominal pain and collapse. The sound passed 
into the bladder goes an indefinite distance up into the abdominal 
cavity through the rent in the bladder, while the catheter shows 
that the bladder is empty. In the event of extra-peritoneal 
rupture the symptoms are less severe and urinary extravasation 
appears in the course of a few hours. In such case the sound can 
not be passed such a long distance as when the opening is into the 
peritoneal cavity. Sterile salt solution injected into the bladder 
causes no swelling of the viscus as determined by bimanual pal- 
pation if the rupture is intra-peritoneal. Cystoscopy is out of the 



DISPLACEMENTS 461 

question in these cases because of the grave condition of the 
patient. The abdomen should be opened at once. 

Contraction of the bladder is generally clue to cystitis, to inflamma- 
tory adhesions about the bladder, or to a habit of frequency of 
micturition. The symptom is frequency of urination. The diag- 
nosis is established by injecting fluid until the patient has a strong 
desire to urinate or until the fluid is expelled. Measure the amount 
in a glass graduate. It may be only an ounce or two. By cystos- 
copy the bladder will not dilate well when air is admitted and the 
mucous membrane is wrinkled and corrugated; scar tissue will be 
seen if the contraction is due to old inflammatory processes in the 
bladder. 

Upward displacement of the bladder not associated with dis- 
tention is met with in the case of large fibroids of the uterus. The 
bladder is flattened out on the anterior face of the tumor and its 
fundus may even reach as high as the umbilicus. The relative 
infrequency of urinary symptoms in these cases has always been a 
source of surprise to me. Palpation of the tumor will show, pro- 
vided the abdominal walls are lax and thin, an elastic swelling on 
the anterior aspect of the tumor. The passage of the sound into 
the bladder permits the mapping out of its confines. This pro- 
cedure should never be omitted by the surgeon in the diagnosis of 
large fibroids, for the operator should know where the bladder is 
situated before he opens the abdomen, rather than cut into it by 
mistake in the course of an operation for the removal of a tumor — 
a not very rare happening. 

Downward displacement of the bladder occurs whenever the 
anterior segment of the pelvic floor is displaced downward. It is 
generally associated with uterine prolapse and with rupture of the 
perineum and pelvic floor. When the base of the bladder projects 
into the anterior wall of the vagina the condition is known as 
cystocele. The diagnosis of this condition is to be found in Chapter 
XX., page 366 (see also Chapter V., The Mechanics of the Pelvic 
Floor) page 221. It is rare for the entire bladder to be in the sac of 
a complete uterine prolapse, a portion of the organ remaining in the 
pelvis in almost all cases. When a part of the bladder is prolapsed 
and a part is behind the pubic bone the organ may assume an hour- 
glass shape. Exceptionally, in the presence of procidentia, the 
bladder becomes detached from its connections with the vagina 



462 DISEASES OF THE BLADDER 

and remains in its normal situation. The diagnosis of the situation 
of the bladder is established by means of the sound passed into the 
bladder. (See Fig. 89 , page 227.) In cases where the base has been 
displaced the ureteral orifices are displaced also, although they 
always bear the same relation to the internal orifice of the urethra. 

Lateral displacement occurs when an inflammatory mass or tu- 
mor occupies one half of the pelvis, the bladder being obliged to 
expand into the opposite half of the pelvis. Here the asymmetry 
may be determined with a sound, measurements being taken of 
the depth of the bladder in various directions. 

Hernia of the Bladder. — The bladder wall may, very rarely, be 
pushed into the inguinal and femoral canals and form a part of a 
hernia. 

E version of the bladder through a dilated urethra is a rare form 
of displacement. The entire thickness of the bladder wall is in- 
volved and the protruded mass appears as a bright red tumor 
projecting from the urethral orifice. The mechanism of the pro- 
duction of eversion appears to be as follows: Given, a large urethra, 
as in the congenital enlargement described on page 444, the patient 
strains excessively, perhaps because of constipation or diarrhea, 
and the posterior wall of the bladder is forced into the neck of the 
bladder and then into the urethra, to present, in the course of 
time, at the external orifice. In extreme instances the entire 
bladder has been found turned inside out through the urethra. 
Eversion is observed most frequently in young children, and in the 
very old. The diagnosis is made by noting the ureteral orifices in 
the prolapsed mass, by passing a sound introduced in the urethra 
round the tumor and finding that it is attached nowhere to the 
urethral wall, and by observing that the sound will not pass beyond 
the neck of the bladder. An anesthetic is necessary in order to 
reduce the eversion. When the bladder wall has been pushed back, 
the fact that the urethra is dilated will be apparent, and the bladder 
can be filled with fluid, and also inspected with a cystoscope. 

FOREIGN BODIES IN THE BLADDER 

Calculi. — The foreign body most frequently found in the bladder 
is a calculus or stone. This may have reached the bladder from 
the kidney through the ureter — in which case the stone is said to 



FOREIGN BODIES IN THE BLADDER 463 

be primary — or it may have formed in the bladder about some 
other foreign body, such as a silk ligature, or the products of 
inflammation. In the latter event it is a secondary stone. In- 
crustations of phosphates and urates on the bladder walls following 
inflammatory processes are the commonest forms of calculi. Small 
uric acid and oxalic acid calculi may come down from the kidney, 
stay in the bladder, and attain considerable size by the accretion 
of layers of deposit of urates and phosphates. 

Calculi are most often found in children and in old women. 

The female urethra is short and frequently small stones from 
the kidney are passed without causing severe symptoms. On the 




Fig. 186.— Stone in the Bladder. (Knorr.) 

other hand, foreign bodies are introduced from without much more 
easily than in the male, therefore the presence of extraneous 
foreign bodies and consequently of some form of stone — for foreign 
bodies are usually encrusted after they have been in the bladder 
for any length of time — is more common in the female than in the 
male bladder. 

Other Foreign Bodies. — Substances introduced through the 
urethra are: pieces of catheters which have broken off, pieces 
of rubber tubing, hairpins, seeds of cherries and other fruits. It is 
a rare but not impossible occurrence for a nurse to break off a glass 
catheter in the bladder. Many of the fenestrated glass catheters 
are weakened by the holes of the fenestrations being too near 



464 DISEASES OF THE BLADDER 

together, and on this account the catheter is more apt to be cracked 
in this situation. 

Once, ten years ago, I was performing an abdominal operation 
for retroversion in a private hospital. This operation had been 
preceded at the same sitting by a curetting and trachelorrhaphy, 
and the precaution of passing the catheter at the close of the va- 
ginal operations had been neglected so that when the abdomen 
was opened the bladder was found to be full. A nurse was asked 
to pass the catheter. She did so, using a fenestrated glass instru- 
ment of the common pattern, and announced that there was no 
urine in the bladder. On withdrawing the catheter, however, one 
and a quarter inches of the end were missing. Removing my 
gloves, I passed another catheter and withdrew eight ounces of 
urine. I was then able to palpate by my finger in the vagina the 
broken catheter lying on the base of the bladder. Introducing 
an Emmet curette forceps through the urethra I succeeded in 
pushing the broken glass into the forceps by means of my finger 
in the vagina so that it lay in the long axis of the fenestration of 
the blades. The catheter end was removed through the urethra 
without injuring the bladder or urethra in the slightest degree. 
The broken piece exactly matched its fellow, but the bladder was 
irrigated to make sure that no spicule of glass was left behind. 
The operation was finished and the patient made a convalescence 
free from urinary symptoms. Since this accident I have discarded 
this form of glass catheter and use only the sort that has a single 
opening in the end or side. 

Foreign bodies may enter the bladder from the vagina, the most 
common of these being a neglected pessary, which has ulcerated 
through; or from the abdominal cavity, as a silk ligature which 
was about the pedicle of an ovarian cyst, then became infected 
and reached the bladder by means of adhesive inflammation; or 
the contents of a dermoid or echinococcus cyst which has opened 
into the bladder. The bones of an extra-uterine fetus have been 
known to find their way into the bladder. 

Foreign bodies which remain in the bladder a considerable 
length of time invariably set up a cystitis. This process may be 
limited to a portion of the organ, as in the case where the irritating 
foreign body, especially in the case of stone, is situated in a loculus. 
As a rule, the cystitis is general. Large foreign bodies have been 



CYSTITIS 465 

known to ulcerate through the bladder into the vagina or into the 
peritoneal cavity. 

Symptoms. — The symptoms of foreign bodies are those of cys- 
titis: there is frequency of micturition, pain in the region of the 
bladder, cloudy, perhaps bloody urine. A stone may be carried 
in the bladder for years without producing any more symptoms 
than a frequency of micturition. A freely movable stone causes 
exaggeration of symptoms on moving about, especially on riding 
and driving; it may be at these times only that the urine is bloody. 

Diagnosis. — The diagnosis is made by palpation and inspection. 
Many foreign bodies may be felt by the finger in the vagina, the 
obstacles being a foreign body of small size and a thickened bladder 
wall. The base of the bladder should be palpated always. The 
sound introduced per urethram hits a stone or encrusted foreign 
body with a metallic click. Sometimes a stone in a loculus, or one 
covered with a thick layer of mucus, will not give this click and 
phosphatic deposits on an ulcerated area give a grating feeling to 
the sound similar to that of a round calculus. The drumming of 
the bladder wall on the end of the catheter — so-called " stammering 
of the bladder," little taps being given to the catheter, — must not 
be mistaken for the metallic click. This drumming is a physio- 
logical affair and may occur in healthy bladders as far as we know 
at present. It occurs surely in the course of catheterization of 
patients who present no bladder symptoms. The exact diagnosis 
of stone is made by means of the cystoscope, the patient being in 
the knee-chest cystoscopic position. Unless the foreign body is 
adherent to the bladder wall it will drop to the most dependent part; 
in any event it may be seen through the cystoscope. 

The electric cystoscope with water-distended bladder is well 
adapted for the inspection of small calculi and especially for those 
that are pocketed. (For electric cystoscopy see Chapter VIII., 
page 117.) 

CYSTITIS 

Inflammation of the bladder is much more infrequent in women 

than in men. It is a disease of adult life and is especially common 

at the times of excessive pelvic congestion, that is, during the 

menstrual periods, in pregnancy, during congestive pelvic disease, 
30 



466 DISEASES OF THE BLADDER 

and at the menopause. True cystitis is rare during childhood, but 
bacteriuria is not uncommon. (See Chapter XXVIII., page 579.) 

Classification. — Cystitis may be classified as acute or chronic, 
circumscribed or diffuse, or according to the, clinical manifestations. 
Some day a classification based on the bacteriology will be the 
standard. At present a clinical classification seems to be most 
available for diagnostic purposes. The symptoms of cystitis will 
be considered as a whole after the different clinical forms have 
been described. 

Etiology and Pathology. — The immediate cause of cystitis is 
always a bacterium. Many sorts of bacteria are found in the 
bladder under conditions of health, just as in the cases of the 
other orifices of the body that are lined with mucous membrane. 
With an unimpaired vis medicatrix naturae the microorganisms 
are short-lived, instance the Klebs-Loeffler bacillus in the nose; 
given impaired vitality and the germs find lodgment and flourish 
in the tissues. The following bacteria have been isolated from 
the bladder, almost always in mixed infections: 

bacillus coli communis, gonococcus, 

streptococcus pyogenes, typhoid bacillus, 

staphylococcus pyogenes, tubercle bacillus, 

staphylococcus albus, bacillus proteus, 

staphylococcus aureus, bacillus lactis aerogenes, 

staphylococcus citreus, bacillus pyocyaneus, 

urobacillus liquefaciens. 

In other words, almost any bacterium may, under favorable 
conditions, enter the bladder and cause a cystitis. What are the 
avenues of entrance and what are the favorable conditions? The 
microorganism may reach the bladder (a) through the urethra, 
as in the case of the gonococcus, which, as far as known, always 
gets into the bladder by this channel, (6) through the ureter, as in 
the case of the tubercle bacillus, which usually descends to the 
bladder in this way, (c) by the blood current, — the typhoid bacillus 
may come in the blood, and (d) by direct extension through the 
tissues from an adjoining organ, as in the case of the bacillus coli 
communis entering the bladder through the walls of an adherent 
and inflamed bowel. 



CYSTITIS 467 

The favorable conditions — the predisposing causes — are: (1) 
local, or (2) general. 1. Local causes are injuries of the bladder, 
either direct trauma inflicted on its mucous membrane, or on the 
musculature of the wall, as instrumentation during difficult labor, 
rough catheterization with a hard catheter, or from stone or other 
foreign body in the bladder, or by displacements of the bladder, 
as from the injuries resulting from childbirth, from tumors, or from 
overdistention. Pregnancy and the catamenia must be regarded 
as local causes, for at these times the congestion of the pelvic 
organs is pronounced, and observation has shown that cystitis is 
more apt to begin then, and if it has existed previously exacer- 
bations are more common both just before the menstrual periods 
and during pregnancy and the puerperium. Anything that excites 
and continues congestion of the pelvic organs must be regarded as 
a cause of cystitis, and therefore excessive venery or masturbation 
may have an etiological significance. Inflammation of adjacent 
organs is a local cause in many gynecological cases, as inflammation 
of the tubes, a pelvic abscess, or dermoid cyst discharging into the 
bladder, or uterine cancer. 

2. Among the general causes are to be classed certain drugs 
taken by the mouth, as cantharides and turpentine, which cause 
congestion of the vesical mucosa and therefore are causes of in- 
flammation, also alcohol taken in excess. Lowered vitality and 
anemia are caused by the wasting diseases, also by any acute 
disease. Skene said that he had noted that in measles and scarlet 
fever the mucous membrane of the bladder suffered like the mu- 
cous membranes elsewhere in the body in these diseases. 

Chronic heart disease and cirrhosis of the liver produce engorge- 
ment of the pelvic organs; old age, by diminishing the tonicity 
of the bladder walls, favors retention and decomposition of urine; 
and paralysis, in the same way, may promote retention, overdis- 
tention, and decomposition. Major operations, by depressing the 
strength and powers of resistance of the system, may be reckoned 
among the causes. " Catching cold" must be regarded as a local 
congestion of unknown origin, which often is the only cause afforded 
by the history of the case. 

Catarrhal Cystitis. — The mucous membrane of the bladder is of 
a deeper shade of pink than normal, and there is an increase in the 
number and the size of the visible blood-vessels. The condition is 



468 DISEASES OF THE BLADDER 

an exaggeration of the hyperemia seen during menstruation and 
pregnancy. No one can say when hyperemia shades into inflamma- 
tion, therefore very little will be said of hyperemia and local hypere- 
mia of the trigone, for instance, and "trigonitis" will be classed 
as localized cystitis. 

Ulcerative Cystitis. — With ulceration there is a loss of epithelium 
in the mucous membrane. An excavation can be seen lined by 
granulation tissue, which bleeds on the slightest touch. There 
may be pus, granular debris, or urinary salts on the surface of an 
ulcer, and, in the healing stage, ridges and irregular elevations are 
visible. 

Exfoliative Cystitis. — This is a rare form of cystitis in which the^ 
mucosa is shed in part or as a whole, with subsequent regeneration. 
It is due, apparently, to the cutting off of the blood supply of the 
bladder caused most often by retroflexion of the pregnant uterus, 
or by protracted delivery. It is an ischemic necrosis, with or 
without bacterial infection. The detached mucous membrane is 
passed per urethram either in small pieces or in one large piece, 
and is apt to be covered by uric acid crystals and to be so much 
disorganized that the recognition of it as mucous membrane is not 
easy. In severe grades, as pointed out by Boldt, the muscular or 
even the peritoneal coats of the bladder may be involved. 

Tuberculous Cystitis. — Tuberculous cystitis is a frequent affection 
and, in the vast majority of cases, is secondary to tuberculous 
disease of the kidney, the infection coming to the bladder through 
the ureter. Rarely it is primary in the bladder, and it may be a 
part of a general tuberculosis. If the disease is secondary to 
tuberculosis of the kidney the manifestations in the bladder are 
most marked in the neighborhood of the ureteral orifice on the side 
of the affected kidney, because in this situation the infected un- 
diluted urine comes into most intimate contact with the mucosa. 
Tuberculosis of the kidney is generally unilateral in its earlier stages. 
The ureteral mons is puffy and swollen, and glistening opaque 
tubercles and ulcerations are seen in the mucosa surrounding the 
orifice. The disease is seldom seen before the ulcerative stage, 
although there is a catarrhal stage which precedes it. In the 
course of time caseation occurs and the tubercles break down, 
leaving a deep, ragged-edged ulcer; the urine containing pus, blood, 
and mucus. The disease may be confined to definite patches in 



CYSTITIS 469 

the bladder; the trigone, base, and posterior walls being most 
often involved; the ulcerations advance slowly in any event; in 
very bad cases the entire bladder may be ulcerated. 

The disease runs a chronic course of many years' duration. In 
making the diagnosis of tuberculous cystitis the history is of aid, 
and if gonorrhea can be ruled out in a patient having a distinct 
family history of tuberculosis, the probability is that the disease 
is tuberculous, especially if the cystitis occurs in a young woman. 
The appearances of the bladder are more or less characteristic: 
glistening, opaque tubercles on a reddened base, breaking down 
to form ulcers with irregular sharp edges and granulating bases. 




Fig. 187. — Tuberculosis of the Left Ureter and Bladder, Showing Crater-like 
Ureteral Orifice and Tubercles of the Bladder Wall. (Knorr.) 

In the late stages the bladder shows contracted areas and ulcera- 
tions. Finding the tubercle bacilli in the urine makes the diagnosis 
positive. In the early stages of the disease they may be few in 
number and hard to find; later, there will be no difficulty, as 
abundant bacilli are in the urinary sediment. 

Hunner and Casper have been able to find tubercle bacilli in 
eighty per cent of all their cases of tuberculosis of the urinary sys- 
tem. Hunner gives the following steps of his technique for finding 
the bacilli : — A catheterized specimen of urine is allowed to stand a 
few hours in a conical urine glass; 5 to 10 cubic centimeters are 
taken from the bottom with a pipette and centrifugalized. The 
heavy deposit is spread on two glass slides that have been pre- 



470 DISEASES OF THE BLADDER 

viously cleansed of grease by alcohol, and are allowed to dry in 
the air or in the incubator. These slides, after fixing by heat, are 
stained in the usual manner by carbol-fuchsin, then they are 
decolorized with a three-per-cent nitric or hydrochloric acid alcohol 
solution, and counterstaineci with methylene blue. Half an hour 
is spent in the examination of each slide under the microscope. 

Inoculation of a guinea-pig is an easy and sure way of estab- 
lishing the diagnosis of tuberculous cystitis. By means of a hypo- 
dermic syringe suck up a little of the urinary sediment and inject 
it under the skin of the groin of a guinea-pig, having first washed 
and shaved the area. If tubercle bacilli are present the enlarged 
inguinal glands will be felt as distinct nodules in the course 
of two or three weeks. A gland removed, sectioned, and stained 
will show the characteristic lesions of tuberculosis and the 
tubercle bacilli. 

In doubtful cases pick off a bit of tissue from the edge of the 
ulcerated area in the bladder, using the cystoscope and the alligator 
forceps, and stain and examine the tissue for tubercle bacilli. 

Rare Forms. — Certain rare forms of cystitis have been described. 
Of these vesicular cystitis consists of the appearance of minute 
vesicles, the size of a pin's head, on a congested bladder mucosa. 
These vesicles may be arranged in bead-like strings on either side 
of the blood-vessels and are regarded as dilated lymphatics. Larger 
vesicles amounting to bullae have been described as occurring in 
the bladder. The little vesicles are not to be confused with the 
tubercles of tubercular cystitis. The vesicles are shiny, translu- 
cent, and have no red base, as in the case of the tubercle. The 
tubercles are opaque and are never arranged in rows. 

Several observers have noted the occurrence in the bladder of a 
patch of horny, epithelial cells arranged in layers, a cornification 
of the mucosa. A. T. Cabot (Amer. Jour. Med. Sci., Feb., 1891) 
described a case in which a membrane of whitish-yellow color and 
hard to the touch, in size forty-five square centimeters and two 
or three millimeters in thickness, was removed by him from the 
posterior wall of the bladder of a man of forty by suprapubic 
cystotomy. The membrane was composed of epithelial cells 
arranged as they are on the surface of the skin. Virchow found a 
similar condition of the mucous membrane of the larynx that he 
called " pachydermia laryngis." 



CYSTITIS 471 

Gierke, according to Hunner, described two cases and found 
seven others in the literature with the following characteristics : — 
Soft nodules or plaques of a yellowish or yellowish-gray color sit- 
uated in the mucous membrane and submucosa of the bladder 
presenting an appearance not unlike the Peyer's patches of the 
intestine in typhoid fever. They are round or oval, isolated or 
connected, and vary in size from one millimeter to two centimeters 
in diameter. The mucosa surrounding a plaque is reddened. They 
have no characteristic arrangement and their pathology and etiology 
are obscure. 

Symptoms of Cystitis. — The chief symptom of cystitis is frequency 
of passing urine accompanied by pain, it being most marked when 
the seat of the disease is near the neck of the bladder. The frequency 
varies under differing conditions and at different times, from once 
an hour to every five minutes. There may be great straining on 
urination with the passage of only a few drops of urine at a time. 
This is known as strangury (from (rrpdyg, a drop, and oZpov, urine). 
Patients of a nervous temperament suffer more acutely with a 
milder grade of bladder inflammation than do their thicker-skinned, 
more stoical sisters with a cystitis of severe type. Hyperemia of 
the trigone may be associated with frequency and even with pain- 
ful micturition. An important factor in the symptomatology as 
regards its effect on the nervous system is the patient's fear that a 
toilet may not be accessible when the desire to urinate comes, 
therefore she stays at home, becomes a recluse, and is melan- 
cholic. Loss of sleep because of frequency of micturition is another 
important factor to consider in cases of cystitis in deciding as to 
the causation of nervous debility. More or less constant pain in 
the region of the bladder is a symptom of an ulcer of the base of 
the bladder. An ulcer or fissure may be painful only when the 
bladder is distended and the walls of the bladder are on the stretch 
and the surface of the ulcer or fissure is bathed in irritating urine. 
A rise of temperature may occur in acute cystitis, but in the chronic 
stages fever is generally absent. It may occur, however, in pyelitis, 
and irregular elevation of temperature should lead suspicions in 
that direction. 

Diagnosis of Cystitis. — The diagnosis rests on the results of the 
examination of the urine and on .the physical examination. 

The Examination of the Urine. — The urine in cystitis is cloudy 



472 DISEASES OF THE BLADDER 

and contains pus and large pavement epithelial cells. Other vari- 
able constituents are blood — normal and abnormal — urates, phos- 
phates, crystals, and bacteria. To be sure that pus in the urine is 
from the bladder and not from the external genitals or the vagina 
it is necessary to procure a catheter specimen, and even then the 
point of origin of the pus may be the ureter or the kidney. If there 
are present casts, a large amount of albumin, and small epithelial 
cells, also if the passing of urine filled with pus alternates with 
the passing of clear urine, the indications point toward kidney 
disease. Kelly has called attention to the fact that when the 
bladder urine is alkaline from a proteus infection the pus cells 
become converted into mucoid substances and the urine is slimy 
and stringy, while no well-defined pus cells are found in the urine. 
The presence of abnormal blood in the urine signifies that the 
blood has been in the urine a considerable time, and therefore its 
origin is more likely to be the kidney than the bladder. If blood 
is effused rapidly, however, it will appear in the urine as normal 
blood, be its origin the bladder or the kidney. 

In almost all cases of cystitis the urine is acid when freshly passed, 
but it quickly becomes alkaline on standing. In some cases the 
urine in the bladder is made alkaline by the bacillus proteus or 
other bacteria. This happens in cases of dislocated bladder where 
there is present residual urine. There is nothing distinctive about 
the specific gravity of cystitis urine, and many of the old views 
as to its characteristics must be revised in the light of our present 
knowledge of the bacterial origin of all forms of cystitis. 

The odor of a cystitis urine is strong and may smell of decom- 
position even though the colon bacillus is present and the reaction 
is acid. There may be gas in the urine caused by the decomposition 
of diabetic urine due to the saccharomyces bacterium, or to the 
presence in the bladder of the gas bacillus, also in cases where 
there is a fistula connecting the bowels with the bladder. 

Palpation. — Palpation of the bladder by the bimanual touch 
elicits areas of tenderness, especially if the cystitis is situated in 
its common location, the base of the bladder. Such areas may 
be mapped out by means of the catheter-sound in the bladder, 
the patient telling when the sensitive spot is touched. Thickening 
of the bladder wall is appreciated by palpating the base of the 
bladder with the finger in the vagina, and also by noting the 



CYSTITIS 473 

thickness of the tissues between the tip of the sound in the bladder 
and the vaginal finger; a contracted bladder may be felt as a hard, 
irregular lump. In acute cystitis vaginal palpation shows that 
the bladder is the seat of extreme tenderness, but further than 
that palpation is not available without an anesthetic. 

Cystoscopy. — Cystoscopy may be employed in all cases of cystitis 
except in the most acute stages. Here it is wiser, generally, to 
make soothing treatments until the active symptoms of fever, 
strangury, and excessive tenderness have abated, before using 
the cystoscope. The use of cocaine in the urethra and the knee- 
chest position as described in Chapter VIII., page 110, best facili- 
tate inspection of the interior of the bladder. In the case of trigo- 
nitis and the milder grades of bladder inflammation the artificial 
anemia caused by the high position of the pelvis, coupled with 
the air distention of the viscus, tend to do away with the character- 
istic signs, therefore in these cases the raised pelvis dorsal position 
should be used. 

All parts of the bladder should be examined systematically in 
order. Free blood is wiped off the surface by minute pledgets of 
cotton held in the alligator forceps and thus is made plain the 
difference between blood on the surface of the mucosa and blood 
effused in the tissues. Collected urine is removed by the suction- 
tube and bits of urinary salts obstructing the view are taken away 
with the alligator forceps. If the disease is localized the congested, 
diseased areas of the bladder wall are contrasted with the paler, 
healthy parts. Cultures are made from ulcerated areas, the ure- 
teral orifices are inspected, and the character of the fluid issuing 
from them is noted. It is never justifiable to pass a ureteral catheter 
into a presumably healthy ureter in the presence of acute or sub- 
acute cystitis, until the nature of the infection in the bladder is 
known, because of the great danger of carrying infection into the 
ureter, and until all other attainable facts as to the existence of 
kidney disease are in hand the physician should be content not 
to invade the ureters. In the presence of infection the bladder 
should be irrigated with sterile one-per-cent boric acid solution 
before ureteral catheters are passed and such an irrigation should 
be the last step in the cystoscopy. 



474 DISEASES OF THE BLADDER 



VARIX OF THE BLADDER 

Varicose veins of the bladder is a very rare condition, although 
from a priori considerations it should be common. It has been 
found in men associated with rectal hemorrhoids. Knorr shows 
in his book a beautiful plate of a varix in the neighborhood of the 
right ureteral orifice as seen through the electric cystoscope. Hem- 




Fig. 188. — Varix of the Bladder near the Opening of the Right Ureter. (Knorr.) 

orrhage from the bladder is the chief symptom, and difficulty of 
urination may be present. Cystoscopy affords the only opportunity 
for an exact diagnosis. 



FISTULA OF THE BLADDER 

A vesical fistula is an abnormal channel of communication 
between the bladder and an adjacent organ. Fistulse are of three 
sorts: — 1. Vesico- vaginal, 2. vesico-uterine, 3. vesico-intestinal and 
other fistula?. 

1. Ves ico- Vaginal Fistula 

Frequency, Etiology, and Pathology. — Vesico- vaginal fistulse vary 
in size from a pin-point opening to a large hole involving the 
entire base of the bladder. The cervix may be involved, in which 



FISTULA OF THE BLADDER 475 

case the fistula becomes vesico- uterine as well as vesico-vaginal. 
The opening is generally situated in the median line in the case of a 
fistula involving the cervix as well as the vagina, according to 
Thomas Addis Emmet ("Vesica- Vaginal Fistula/' 1868). In 
other fistula? the opening may be in any part of the vesico-vaginal 
septum. It is irregular in outline in the months following its 
formation and the edges are thickened and ulcerated; later, the 
opening is circular or oval and the edges are smooth, thin, and 
hard, the tendency of the fistula being to close by granulation and 
cicatrization. A clean-cut fistula formed artificially by operation 
for the purpose of draining the bladder in cases of cystitis will close 
spontaneously in a short time unless the operator takes the pre- 
caution to stitch the cut edges of the bladder mucosa to the edges 
of the vaginal mucous membrane. A small opening which has been 
caused by sloughing may close of itself, but, in many cases, these 
are the fistula? that persist for years. 

In the case of large fistula? there may be present cicatricial 
bands radiating from the fistula over the bladder walls. Vesico- 
vaginal fistula? are the most common of the fistula? of the genital 
tract. They are not nearly so common as they used to be forty 
years ago. During the first twelve years of the Woman's Hospital 
in the State of New York up to the year 1868, Dr. Emmet had 
under his charge 296 cases of genital fistula?, including in this 
number the cases of vesico-uterine and recto-vaginal fistula, the 
last, however, forming only about six per cent of the whole. 
At the present time I venture to say that few gynecologists having 
an active hospital service and a large private practice see more 
than two or three cases of vesico-vaginal fistula in the course of a 
year. A perusal of the recent annual reports of half a dozen metro- 
politan hospitals having large gynecological clinics reveals the fact 
that in no one hospital were more than three cases of vesico-vaginal 
fistula seen during any one year. 

The cause of vesico-vaginal fistula is, in a vast majority of cases, 
ischemic necrosis of the vesico-vaginal septum due to impaction of 
the child's head in the pelvis during prolonged labor. Very rarely 
fistula may result from the use of the obstetric forceps. Emmet 
saw only three cases where this had occurred. It is possible that 
at the present time when forceps are used more frequently and 
women are neglected in labor less often, injuries from instruments 



476 



DISEASES OF THE BLADDER 



may occur with relatively greater frequency. If the forceps or 
other instruments cause the fistula there will be a discharge of 
urine immediately after labor, otherwise not until the slough has 
separated — in a week or ten days. In two cases that I operated on 
for extensive vesico-vaginal fistula there was a history of incon- 
tinence of urine following immediately after a difficult forceps 




Fig. 189.— Diagrammatic Representation of the Different Sorts of Genital 

Fistulae. (Dudley.) 

delivery in each instance. Embryotomy had been performed in 
one. Other causes of vesico-vaginal fistula are: sloughing resulting 
from cancer of the bladder, from a large vesical calculus or from 
an ill-fitting pessary, or the burrowing of a pelvic abscess. 

Symptoms.— The symptoms of vesico-vaginal fistula consist of a 
constant dribbling of urine, beginning at once after the receipt of 
the injury if it is due to forceps or other obstetrical instruments 



FISTULA OF THE BLADDER 477 

and in a week or ten days if due to a slough from prolonged pressure 
and ischemia of the vesico- vaginal septum. In the latter event 
we expect to find present a rise of temperature and a purulent 
vaginal discharge. The skin of the vulva, perineum, and the 
insides of the thighs is excoriated, reddened, and, in cases of long 
standing, thickened. The hairs of the vulva and the edges of the 
fistula are encrusted with urinary salts. 

The patient suffers extremely from the irritation caused by the 
urine and from being constantly wet and deprived of proper rest, 
so that the nervous system is deranged and in many cases she 
becomes melancholic. The nutrition is impaired, and cachexia and 
poor health result. 

If the vaginal outlet is uninjured, as occasionally happens, some 
patients with vesico- vaginal fistula are able to retain a considerable 
amount of urine in the vagina while lying down, the urine being 
passed when the patient assumes the erect posture. The subject 
of a vesico-vaginal fistula may become pregnant, an event that 
occurred in a patient who was under my observation, and Winckel 
has reported an instance of a woman with a vesico-vaginal fistula 
who became pregnant, was delivered at term, and subsequently 
the fistula healed spontaneously. 

Diagnosis. — The patient should be placed first in the dorsal 
position. If there is dermatitis of severe grade it will be advisable 
to treat this condition before making an exact diagnosis. To 
this end the urinary salts should be removed carefully, the parts 
bathed in boric acid solution — one per cent — and thoroughly 
dried with soft lint, a pledget of cotton being placed temporarily 
in the vagina if necessary to prevent urine from coming out until 
the parts are dry. Then all the region of the vulva and insides of 
the thighs and also the introitus vagina) should be smeared with 
a freshly made ointment of oxide of zinc. This treatment should 
be repeated twice a day and the vulva should be constantly covered 
with soft napkins of washed cheese cloth or old linen, the attempt 
being made to keep the parts as dry as possible. Prolonged, hot 
six-quart vaginal douches should be given twice a day before the 
drying and the treatment with the ointment. Dr. Emmet always 
laid much stress on the douches and said that his good results 
with vesico-vaginal fistula depended in large measure on the faith- 
fulness of the nurse. The urine should be kept diluted by giving 



478 DISEASES OF THE BLADDER 

much fluid by the mouth — milk is especially valuable in these 
cases — and rendered unirritating and aseptic by the adminis- 
tration of urotropin, ten grains every four hours. 

With the patient in the Sims position and with a Sims speculum 
in the vagina the fistula may be inspected, note being taken of its 
size, the condition of the edges, whether inflamed and thickened, 
or encrusted with salts, or cicatricial and thin. The situation of 
the ureteral orifices should be determined in every case so that 
they may not be included in the line of sutures when repair is 
undertaken. Also, if the opening is of sufficient size, the condition 
of the bladder wall may be seen, whether free from lime salts and 
how much inflamed and the openings of the ureters may be in- 
spected directly. The capacity of the bladder, whether contracted 
or not, is determined by passing a sound through the urethra 
and, in the case of a large opening, by exploration with the finger 
passed through the fistula. 

In the case of very small fistula? nothing but a fine probe can 
be passed through the opening. In this event the probe is intro- 
duced into the bladder through the urethra and an attempt is made 
to cause its point to emerge in the vagina. In these cases it is 
well to put the patient in the elevated pelvis position and perform 
cystoscopy in an attempt to see the fistulous opening and probe 
it with the ureteral searcher. At the same time the condition of 
the bladder mucosa is inspected. In the case of minute fistula? 
which can not be found with the probe, inject the bladder with 
milk and water or with aniline blue and water, the patient being 
in the dorsal position and a speculum in the vagina, and watch for 
the appearance of the colored fluid from the opening in the vaginal 
wall. Knowing the situation of the fistula a fine probe can almost 
always be passed through it. The amount of scar tissue in the 
vagina must be determined carefully because the repair depends 
on the amount of freely movable tissues at the disposal of the 
operator. The scar tissue is felt by the palpating finger as a hard- 
ened and roughened area. The finger introduced through a 
fistulous opening into the bladder feels the velvety mucous mem- 
brane of the bladder and also the rough lime salts, if they are 
present. 

Differential Diagnosis. — A vesico-vaginal fistula must be differ- 
entiated from a ureteral fistula into the vagina. 



FISTULA OF THE BLADDER 479 

In the latter event there will be a history of discharge of urine 
in the natural way and also of a more or less constant leaking. 
Injecting the bladder with milk and water and drying the vagina, 
search is made for an opening in the vaginal vault that gives exit 
to fluid having the odor of urine. If urine escapes from the os 
uteri, a vesico-uterine fistula is the diagnosis. In cases of doubt 
inject the bladder with milk and water and then see it issue from 
the os. Don't pass a ureteral catheter or probe into a suspected 
ureteral fistula nor into the ureteral orifice in these cases, because 
of the danger of infecting the ureter and causing ureteral and 
renal disease. 

2. Vesico-uterine Fistula 

This form of fistula is not so common as vesico-vaginal fistula 
and is more often due to a direct tear from the uterus into the 
bladder during labor, than to sloughing following bruising of the 
tissues. The lower portion of the tear through the cervix generally 
heals, leaving a fistulous opening above. The symptoms are 
dribbling of urine more or less constantly. Some of the urine may 
be passed through the urethra and yet there may be a leaking. 
Filling the bladder with milk and water and noting that the white 
fluid comes from the os uteri establishes the diagnosis, also passing 
a sound or probe through the urethra, the end is passed through 
the bladder fistula into the uterus. Another sound passed into the 
uterine cavity through the cervical canal meets the first sound 
with a metallic click and imparts a sensation of contact to the 
first sound or probe. 

Vesicc-utero-vaginal fistula consists of an opening between 
bladder, cervix, and vagina resulting from extensive injury of the 
cervix. Emmet thought it of more frequent occurrence in women 
who have borne a number of children and have relaxed abdominal 
walls. The defect is apt to be found partially bridged over by 
granulation and cicatrization, or it may be entirely closed with 
the exception of a small fistula in the lower cervix. 

3. Vesicointestinal and Other Fistula 

Cases of communication between the bladder and the intestine 
have been reported but they are rare and most commonly follow 



480 DISEASES OF THE BLADDER 

operative procedures. R. Harrison reported a case of fistula 
between the colon and the bladder in which bubbles of gas escaped 
through the urethra, and C. P. Noble published a case of recto- 
vesical fistula following an ischio-rectal abscess, which had existed 
five years before. Gas and pieces of fecal matter were passed per 
urethram. 

An abscess of the Fallopian tube or of the ovary may open into 
the bladder, and not very infrequently a suppurating dermoid 
tumor discharges in this way. The presence of cystitis and finding 
the contents of a dermoid, such as teeth, bone, or hair, in the 
bladder, or if passed from the urethra, points to the seat of fistula. 
Bone from a macerated extra-uterine fetus has been known to 
find its way into the bladder and to form the nucleus of a 
stone. The sudden appearance of a large amount of pus in the 
urine together with the symptoms of acute cystitis should lead to 
the suspicion that a tubo-ovarian or other pelvic abscess has dis- 
charged into the bladder. If the patient has been under previous 
observation and an abscess has been diagnosed, palpation will 
show it to be collapsed. Cystoscopy is the only sure means of 
making a diagnosis of fistula in such cases, the opening being 
found and probed by sight. Bimanual palpation shows the pres- 
ence of an inflammatory mass adjacent to the bladder wall in this 
class of fistulse. 



NEW GROWTHS OF THE BLADDER 

Neoplasms of the bladder are either secondary to a malignant 
growth in an adjacent organ, — perhaps by direct extension, as in 
the case of carcinoma of the cervix, or perhaps by metastasis from 
cancer of a distant organ, — or they are primary in the bladder 
itself. Primary tumors of the bladder are relatively rare, being 
from three to five times less frequent in women than in men. They 
are most often observed between the ages of forty and sixty, but 
may occur at any age, though of very unusual occurrence before 
thirty. Nothing is known of their causation. They are to be 
classed as benign and malignant. The benign are: papilloma, 
fibroma, myoma, and adenoma; the malignant are: malignant 
papilloma, carcinoma, and sarcoma. The tumors may spring from 



NEW GROWTHS OF THE BLADDER 481 

the mucosa, from the submucosa, or from the muscular layer, 
and they are more apt to be situated on the base or on the posterior 
wall, and show a tendency to be single rather than multiple. E. 
Hurry Fenwick, whose experience with bladder tumors has been 
extensive, says: — " Broadly speaking, the cystoscopist will en- 
counter two well-marked varieties of vesical tumors: the villus- 
covered and the bald. Those clothed with villous processes may 
be benign or they may be malignant, but the smooth-surfaced 
groups are almost always malignant, more especially if they occur 
after the age of forty-five." 

Symptoms. — The symptoms of bladder tumors in general are, 
sudden stoppage of the urine with resulting pain (in the case of 
pedunculated growths), and intermittent hemorrhage at the end 
of urination, or mixed with the urine. Renal pain in the kidney 
whose ureteric orifice is nearer the tumor in the bladder is a not 
uncommon symptom. Spontaneous coagulation of the urine in a 
vessel (fibrinuria) due to the excess of fibrin discharged with the 
blood in the urine has been observed only in the case of bladder 
tumors. Cystitis is a late manifestation. Frequent micturition is 
common, especially if the base of the bladder and the trigone are 
affected. 

Diagnosis. — The diagnosis depends on the history, on palpation, 
on the cystoscopic appearances, and on the microscopic examination 
of shreds in the urine and tissue removed from the bladder. Malig- 
nancy is distinguished from benignity only by the greater pre- 
ponderance of pain and induration of the tissues in the former. 
Certain distinguishing characteristic features will be taken up 
with each disease. Lincoln Davis (Annals of Surgery, April, 1906), 
from an analysis of forty-five cases occurring in the Massachusetts 
General Hospital, thinks that the important diagnostic feature of 
malignancy of bladder tumors is the infiltration of the underlying 
bladder wall, and that the recurrence of epithelial tumors does 
not mean necessarily that they are malignant. The electric cys- 
toscope with water-distended bladder is especially well adapted to 
the inspection of bladder tumors and very beautiful pictures are 
obtained of the villi of a papillomatous growth floating in the 
bladder fluid like the tentacles of a sea anemone. 

31 



482 DISEASES OF THE BLADDER 



Benign Tumors 

Papilloma. — Papillomata are the most common of all vesical 
tumors. The name papilloma is given to pedunculated tufted 
tumors, but the shape does not necessarily indicate their patho- 
logical structure, so that it happens that papilloma, although com- 
monly made up of submucous connective tissue — a fibroma, and 
therefore benign — may be an outgrowth of the epithelial tissue 
of the mucosa and therefore malignant. The benign papilloma 
is made up of a framework of connective tissue richly supplied 




Fig. 190. — Papilloma (Fibroepithelioma) of the Bladder. (Knorr.) 

with blood-vessels and covered with pavement bladder epithelium. 
It has a branching, villous appearance, the villi are often of extreme 
thinness and resemble chorionic villi, or they may be short and 
stunted and some may be covered with white phosphatic deposits. 
The villi may be so short that a papillomatous growth may appear 
through the cystoscope to be smooth on first inspection ; in this event 
it looks white, differing from the smooth reddish or reddish- white 
surface of an epithelioma. These growths are generally single in 
their early stages and the base never reaches downward beyond the 
submucosa. They vary in size from a pea to a hen's egg, the latter 
being rare, and are more commonly found in the neighborhood of 
the ureteric orifice, outside the trigone. The mouth of the ureter 



NEW GROWTHS OF THE BLADDER 483 

nearer the tumor is reddened and is converted into a furrow instead 
of being a little slit. The surrounding mucosa of the bladder is 
generally reddened and swollen. If the pedicle is long the growth 
will float about and is likely to plug the internal orifice of the 
urethra, and therefore cause retention. The more sessile the 
tumor and the further it is situated toward the posterior wall, the 
less likely is this result to occur. 

The first symptom of papilloma is blood at the end of micturition ; 
later the amount of blood lost may be alarming. An ache in the 
kidney on the side of the body on which the tumor is situated is a 
symptom of the advanced stages when the growth has increased 
in size. This ache is thought to be due to ascending infection of the 
ureter and kidney, with or without hydronephrosis. Impeded 
urination occurs if the tumor obstructs the urethral orifice, and 
cystitis may be a late result. The diagnosis rests on these symp- 
toms, on the finding of a tumor by vaginal palpation of the bladder 
base, and on the cystoscopic appearances as described above. 
The microscopic examination of pieces of tissue passed in the urine 
or removed by the alligator forceps will alone settle the diagnosis 
of the sort of tumor present. 

Fibroma and Myoma. — These benign tumors are of rare occur- 
rence. A fibroma or fibroid polyp is made up of connective tissue, 
it is usually pedunculated and has a smooth or slightly lobulated 
surface. Its pedicle is well vascularized, but the tumor itself is not. 
The latter fact may be the reason that these tumors are apt to 
undergo myxomatous degeneration. Only a few cases of myoma 
of the bladder have been described. They begin in the muscular 
coat and develop into the cavity of the bladder either as a sessile 
or as a pedunculated growth. In one reported case the myoma 
was on the outside of the bladder. 

Adenoma. — This is a rare benign epithelial tumor of the glandular 
type; it is sessile or stalked, and has a smooth, lobulated, or villous 
surface. The sessile growth, as in the case of the fibroid polyp, 
can be enucleated easily from the bladder wall. 

Malignant Tumors 

Carcinoma. — There are two sorts of primary cancer of the bladder, 
one squamous-celled, and the other cylindrical-celled. The disease 
begins as a small nodule either of the encephaloid, scirrhus, or 



484 DISEASES OF THE BLADDER 

colloid type, and has a tendency to remain localized in the bladder 
for a long time. Later, multiple tumors are found, and ulceration, 
cystic degeneration, and gangrene occur. The bladder wall sur- 
rounding and under the tumor is indurated. The surface of the 
tumor may be covered with villi, which are more vascular than 
in the case of the benign growths; the growth is apt to be sessile. 
The disease extends from the base of the bladder, its usual situa- 
tion, to the ureters, often closing one or both orifices and causing 
renal disease and it either forms a tumor in the bladder or infiltrates 
the bladder wall and the surrounding tissues. The symptoms 
are the same as in papilloma and the diagnosis is made in the same 
manner. Much induration of the tissues in the bladder base 
points toward carcinoma and constant pain in the region of the blad- 
der, and frequency of micturition, are characteristic symptoms. 
Cystitis, with pain in other regions, as in the back and thigh, and 
emaciation, are late manifestations. The exact diagnosis is made 
by the microscopic examination of a portion of tissue either from 
the urine or removed from the bladder through the cystoscope. 

Sarcoma. — Primary sarcoma of the bladder is extremely rare, 
although more frequent than in men. It may occur at any age. 
The tumors are of rapid growth, usually multiple. They are 
sessile and tend to grow out through the urethra. They are red or 
blackish in color and have a smooth surface. 



FUNCTIONAL DISTURBANCES OF THE BLADDER 

As has been pointed out already, any disease that interferes with 
the normal physiology of the trigone and neck of the bladder is 
apt to cause bladder symptoms, as, for instance, hyperemia of 
the trigone or trigonitis, and dislocation of the neck of the bladder. 
In these days of cystoscopy we find many instances of frequency of 
urination where the only discoverable abnormality is injection of 
the mucosa of the trigone. A concentrated urine from lack of 
sufficient ingested fluids, urine containing an excess of uric acid, 
crystals of oxalic acid, or turpentine, cantharides or other irritating 
substances, is a cause often of frequency of micturition. So also 
may be a urethra of caliber insufficient to drain the bladder freely 
and speedily. 



FUNCTIONAL DISTURBANCES OF THE BLADDER 485 

Irritability of the bladder has been the term that has in the past 
cloaked a multitude of sins of omission in diagnosis. In hysteria 
the secretion of large quantities of limpid urine with consequent 
frequency of micturition alternates with scanty high-colored urine. 
Spasm of the detrusor fibers of the bladder with the involuntary 
discharge of urine occurs sometimes in this disease, and hysterical 
retention is frequent. 

When there is spasm of the neck of the bladder in hysteria there 
may be great difficulty in starting urination. Incontinence may 
occur with an attack of epilepsy. In the case of locomotor ataxia 
there is lack of control over the bladder, beginning as a delay in 
starting micturition; after the flow has begun it stops suddenly, 
then starts again, and when the bladder seems to be emptied urine 
is passed into the clothes. 

In this disease there may be also partial or complete retention 
with incontinence from over distention, or vesical tenesmus. 

Retention and incontinence occur in PoWs disease and in in- 
juries of the brain and spinal cord, and also in general paralysis of 
the insane. Retention is noted as a constant symptom in multiple 
sclerosis. 

Where the passing of large quantities of urine is due to mental 
influences, as in the case of apprehension and worry, and not to 
organic nervous disease, the frequency of micturition is limited to 
the day-time, for as a rule such a patient sleeps all night without 
rising to empty her bladder. 

Incontinence of urine is of two sorts, that which occurs in over- 
distention of the bladder, the drop-by-drop kind, with incessant 
dribbling, and the incontinence in the form of intermittent evac- 
uations of large quantities of urine. The first kind is due to any 
cause which distends the bladder with urine, the cause being found 
among the functional and organic diseases of the bladder; the 
second is supposed to be due to faulty innervation of that organ. 
The latter kind is most frequent in children. Many of these children 
are quite normal as to their urinary functions during the day and 
the incontinence is nocturnal only ; others, a smaller proportion, not 
only wet their beds at night, but experience pressing calls to urinate 
during the day, and if not attended to at once, wet their clothes. 
(See Enuresis, Chapter XXVIIL, page 578.) 



CHAPTER XXV 
THE DIAGNOSIS OF DISEASES OF THE URETERS 

Anomalies, p. 486: Double ureter, p. 486. Abnormal situation of 
ureteral orifice, p. 486. Cystic dilatation of an occluded ureter, p. 487. 

Ureteritis, p. 488. 

Stricture of the ureter, p. 489. 

Ureteral calculus, p. 490. 

Prolapse of the ureteral mucosa into the bladder, p. 491. 

Ureteral Fistulse, p. 492: Uretero-uterine, p. 492. Uretero-vaginal, p. 
492. Uretero-vesical, p. 492. Uretero-intestinal, p. 493. 

New growths of the ureter, p. 493. 

The anatomy and physiology of the ureters and the methods of 
examination will be found described in Chapter VIIL, page 104. 

ANOMALIES 

Anomalies of the ureter are rare. One ureter has been found 
wanting, just as one kidney is sometimes absent. It is the rule 
that extreme degrees of ureteral malformations are associated with 
non- viable fetuses. 

Double ureter is the anomaly most frequently observed. The 
duplication may start at the kidney from two separate pelves and 
then unite at some point below to form one canal to the bladder, 
or it may continue double and enter the bladder by two orifices, one 
behind the other. Cases are reported in which a double ureter was 
found on each side in the same patient. The anomaly has little 
if any clinical importance and is discovered in the course of cystos- 
copy, during operations on the kidney, or at autopsies. 

Abnormal Situation of Ureteral Orifice.— The ureteral orifice has 
been found in one of the following situations: the vagina, the 
urethra, near the external meatus, and under the prepuce of the 
clitoris. 

The patient suffers from persistent leakage of urine, but at the 
same time empties her bladder at regular intervals. The importance 
of finding out whether the abnormally placed ureteral orifice is 
the only outlet of a ureter or a supernumerary orifice is apparent. 

485 



ANOMALIES 487 

The history of incontinence existing from birth in a virgin is a 
presumption in favor of abnormal congenital implantation, al- 
though the other causes of incontinence of urine (see Chapter X., 
page 154) must be investigated. If, on the other hand, the inconti- 
nence dates from a difficult labor, or the patient has been subjected 
to some operative interference, the probability is that an abnormal 
situation of a ureteral orifice has been artificially induced. If the 
orifice should be under the prepuce of the clitoris, drying the vulva 
with cotton and watching it will soon determine the source of the 
urine. If the orifice is in the urethra the urethra must be inspected 
through its entire length most carefully with a cystoscope in order 
to find the opening. If in the vagina, the vagina is dried with 
cotton after a speculum has been introduced, and search is made 
for the ureteral orifice. By placing a light packing of dry absorbent 
cotton in the vagina and removing it, one may fix approximately 
the situation of the opening by the situation of the spot of urine 
on the cotton. Does the wet cotton smell of urine? A fine probe 
may be used as a searcher. The bladder is injected with milk and 
water or aniline-blue solution to rule out this viscus as a source of 
the escaping urine. If none of the colored fluid escapes into the 
vagina the opening found in the vagina is a ureteral orifice. Cys- 
toscopy is now performed and search made for both ureteral orifices 
in the bladder. If only one is found the inference is that the opening 
in the vagina is of the opposite ureter. A sterile ureteral catheter 
is passed into it and the catheter palpated by rectal examination. 
If two orifices are found in the bladder a ureteral catheter is passed 
into each and an attempt made to touch one of them with the tip 
of a probe introduced into the orifice in the vagina, thus determining 
a supernumerary orifice, and also on which side of the body, and 
with which kidney it is connected. 

Cystic dilatation of an occluded ureter has been reported. In this 
anomaly the lower end of the ureter has failed to communicate 
with the bladder or with any other part of the genital tract. The 
reported cases have been in adults. In one instance the ureter 
ended in a cyst that was mistaken for a cyst of the vagina. Uterine 
anomalies are apt to accompany the blind ending of a ureter; 
sometimes the ureter may end without dilatation. In either event 
the corresponding kidney is the seat of hydronephrosis or it is 
atrophied. 



488 DISEASES OF THE URETERS 

In all ureteral diseases as well as in cases of suspected nephritis 
the physician must watch each ureteral orifice separately and 
note the character of urine issuing from it, whether clear, turbid, 
or bloody, the force with which the urine is ejected, and the rate of 
frequency of the spurts. It will be found that in the case of a diseased 
kidney of diminished functional capacity the rate of spurting from 
the ureteral orifice will be much diminished — perhaps only once in 
two minutes — while the orifice from the sound kidney spurts 
urine every twenty seconds. Where the kidney is atrophic there 
may be no discharge of urine from the ureter on that side. 

URETERITIS 

Inflammation of the ureter arises from extension of inflammation 
downward from the kidney, upward from the bladder, from some 
cause in the ureter itself — as from a calculus in the ureter — or 
from inflammation in the cellular tissue surrounding the ureter, — 
periureteritis, so-called. As a rule the disease is due to the tubercle 
bacillus, to the gonococcus, or to the colon bacillus, except in the 
cases of stone in the ureter; and ureteritis is secondary to disease 
of the kidney or bladder, therefore its symptoms are often over- 
shadowed by the symptoms of those diseases. Pain in one groin 
extending up to the kidney on the same side, with frequent and 
painful micturition and pus in the urine, are the symptoms of 
ureteritis. The diagnosis is established by the symptoms and by 
the physical examination. Palpation of the base of the bladder and 
the lateral vaginal fornix will detect a tender, thickened cord cours- 
ing toward the posterior pelvis. This cord may be traced a little 
farther by rectal palpation. An acutely inflamed ureter is very 
sensitive. The abdominal course of the ureter may be palpated 
in patients who are not too fat by finding the promontory of the 
sacrum, and rolling the abdominal wall over a point situated two 
fingers' breadth to one side, for at this point the ureter crosses the 
brim of the true pelvis. If the ureter is inflamed at this point the 
patient will experience pain when it is pressed against the under- 
lying bone. 

Through the cystoscope the orifice of an inflamed ureter will 
generally be found in a puffy and swollen mons situated in an area 
of injected mucosa, and cloudy urine may be seen to issue from it. 



STRICTURE 489 



STRICTURE OF THE URETER 

Stricture or obstruction of the caliber of the ureter is much 
more common in women than in men. It may be due to (a) pressure 
from without, to (6) a foreign body in the canal, or to (c) localized 
contractions or narrowing of the lumen caused by inflammatory 
action or to valve formation in the walls of the ureter itself, a. 
Some of the causes of obstruction of the ureter from without are : — 
Ovarian and uterine tumors, cancerous infiltration of the broad 
ligaments, thickened bladder walls, and tumors of the bladder. 
b. The bodies that may obstruct the canal of the ureter are: a 
calculus, a blood clot, or an echinococcus cyst. c. The affections 
of the ureteral walls are ; ureteritis, valve formation in the ureteral 
wall, cancer of the ureter, and gumma of the ureter. 

The situation of obstruction is almost always in the pelvic portion 
of the ureter, rarely in the upper end near the pelvis of the kidney. 
Certain diseases of those mentioned are apt to cause obstruction 
of both ureters. They are: cancer of the cervix extending into 
the bases of the broad ligaments, thickened bladder walls from 
*any cause, and subperitoneal fibroid tumors. In other cases the 
obstruction is apt to be unilateral. 

The symptoms depend on whether the obstruction is of sudden or 
of gradual occurrence. In the former case there is pain in the course 
of the ureter; in the latter, there may be no symptoms at all. If 
the obstruction depends on ureteritis the symptoms will be those 
of ureteritis. Persistent pain in the course of the ureter and pus 
in the urine should lead to an investigation of the cause. The 
diagnosis is made by palpating the ureter by vagina, by rectum, and 
at the pelvic brim, as described in the diagnosis of ureteritis. Search 
should be made for tumors of the pelvis, or for exudates which 
may press on the ureter, remembering that it is in the pelvis that 
obstruction generally occurs. 

Catheterization of the ureter through the cystoscope will show, 
first, that the catheter meets a sudden check, or after meeting a less 
pronounced obstruction it may pass by a narrowed part of the 
ureter, whereupon there is an immediate flow of an ounce or more 
of urine. Perhaps the catheter will be seized at the stricture and 
resist withdrawal. 



490 DISEASES OF THE URETERS 

In introducing a metal catheter into the ureter for searching 
purposes it is well to have the patient in the dorsal position, so that 
after the catheter is in place its further course may be guided by 
the finger in the rectum. In using the gum-elastic or renal catheter 
the examination is begun with the patient in the knee-chest position. 
After the catheter has been introduced the patient is lowered to 
the dorsal position and a bladder catheter passed to let the air out 
of the bladder. The point where the stricture is situated is noted 
by withdrawing the catheter until the eye has become engaged 
in the stricture. At this point the flow of urine stops. Measure 
from the outer end of the catheter to the meatus urinarius. After 
the catheter is out the difference between this measurement and 
the total length of the catheter is the distance of the upper part of 
the stricture from the meatus. To determine the distance of the 
stricture from the bladder, subtract from the last measurement 
the distance from the meatus to the ureteral orifice, as measured 
by the ureteral searcher passed through the cystoscope. 

Graduated whalebone bougies have been used to determine the 
situation and size of strictures of the ureter by various investigators. 
I have had the best results with the Kelly gum-elastic renal catheters 
which contain stylets. 



URETERAL CALCULUS 

A calculus is much more often found in the renal pelvis or in the 
bladder than in the ureter. If the calculus has been lodged in the 
ureter for any considerable length of time it is apt to have a spindle 
shape. The calculus forms in the pelvis of the kidney and works 
down into the ureter; it may be about an inch (2.5 centimeters) 
long and »a quarter of an inch (5 millimeters) in diameter, but 
smaller ones are most often seen. A calculus five inches (12.5 centi- 
meters) long has been observed. Calculi generally lodge just 
below the pelvis of the kidney, at the pelvic brim, and in the pelvic 
floor. Severe pain in the course of the ureter, — often accompanied 
by chills and rigors, rapid pulse, and prostration, — is characteristic 
of the lodgment of a stone in the ureter. Paroxysms of pain 
come on intermittently at variable intervals as long as the stone is 
in the ureter. If the stone moves downward by irregular gradations 



PROLAPSE OF THE URETERAL MUCOSA 491 

its movement may be traced by the appearance of blood in the 
urine. The stone, damming up the urine, causes hydroureter and 
by forming a ball valve in some cases permits the intermittent 
discharge of large quantities of urine. In the course of time the 
kidney is damaged by the back pressure of urine, by infection, or 
by both. 

The diagnosis is established by the symptoms, by palpation, and 
by catheterizing the ureters. A stone in the pelvic floor may be 
palpated by vaginal and rectal palpation and at the pelvic brim 
by abdominal palpation. In the upper part of the true pelvis a 
stone may be felt by high rectal palpation. Through the cystoscope 
a stone may be seen projecting from the ureteral orifice or pushing 
the mons into the bladder; if not, it may be touched with the 
metallic ureteral catheter introduced in the ureter. To detect a 
stone high up in the ureter Dr. Kelly uses a flexible renal catheter 
tipped with a light coating of dental wax, noting, after the catheter 
has been withdrawn, the scratch marks made by the stone on the 
wax. 

The X-rays may be used to detect the presence and situation of a 
ureteral calculus, a competent radiologist being employed to 
obtain a photograph, and also, if the calculus is in the upper portion 
of the ureter, an exploratory incision may be made either through 
the abdomen in the linea semilunaris, or extraperitoneally in the 
lumbar region, as for nephrectomy. If an incision is made plans 
should be perfected beforehand to proceed with an operation for 
the removal of a stone should palpation through the wound reveal 
its presence. 



PROLAPSE OF THE URETERAL MUCOSA INTO THE BLADDER 

Prolapse of the ureteral mucosa into the bladder has been found 
rarely in children and is probably congenital. It is thought to 
depend on stricture of the ureteral orifice causing the lower end 
of the ureter to project into the bladder in the form of a cystic 
tumor, the obstructed ureteral orifice being at some point on the 
circumference of the tumor. Cases of acquired prolapse of this 
sort have been reported and it is likely that the disease occurring 
in children has the same mechanism of causation. 



492 DISEASES OF THE URETERS 



URETERAL FISTULA 



A ureteral fistula is an abnormal opening between the canal of 
the ureter and the surface of the body, or some part of the genital 
or alimentary tract. Ureteral fistula? are congenital, as pointed 
out in the consideration of anomalies, page 486, or they are produced 
by trauma, — most commonly as a result of a difficult labor, — from 
injuries in the course of operations on the pelvic contents or on 
abdominal tumors, or they are caused by ulceration. They involve 
generally the pelvic portion of the ureter. Difficult labor may 
cause sloughing of the uterus or vagina and the ureteral wall, 
leaving a permanent uretero-uterine or uretero-vaginal fistula. The 
ureters have been cut in the course of hysterectomy many times, — 
sometimes when the cause of death has been set down as exhaustion 
or peritonitis. In cases where the patient has survived, the urine 
finds its escape through the drainage tract either in the abdominal 
wall or in the vagina. In one of my cases the ureter discharged 
through the canal of the cervix uteri, a supravaginal amputation 
having been performed for a large fibroid. The opening healed 
spontaneously in the course of a few weeks. This is the issue in 
many cases. Sometimes, however, the fistula is permanent. 

A ureteral stone has been known to ulcerate through the walls 
of the ureter and bladder, finding its way into the latter viscus and 
forming a uretero-vesical fistula. 

In making a diagnosis of ureteral fistula it is to be remembered 
that in the congenital forms the opening of the ureter is generally 
situated low down near the external genital organs, i.e., under the 
prepuce of the clitoris, near the meatus urinarius, or in the lower 
vagina; in the acquired forms, on the other hand, the opening is 
more apt to be higher up near the base of the bladder, or in the 
vault of the vagina. The congenital fistula? have a history of loss 
of urine since childhood, whereas the acquired date from some 
operation, a difficult labor, or from some definite date. If only one 
ureter is involved in the fistula, the usual happening, the patient 
passes urine by the urethra as well as experiencing the discomfort 
of more or less constant leakage. If the fistula is into a vagina 
closed by a tight hymen the loss of urine may occur only when 
the patient is in the erect posture. 



NEW GROWTHS OF THE URETER 493 

The bladder is injected with aniline blue and water, or with milk 
and water, and if there is a fistula involving the bladder and the 
uterus, or bladder and vagina, the escape of the colored fluid will 
be noted. If there is a fistula in the lower pelvic course of the 
ureter a metal ureteral catheter passed into this ureter will go an inch 
or two but not beyond the situation of the fistula, whereas in the 
sound ureter it may be pushed gently well up into the pelvis, some 
three inches. 

Uretero-intestinal fistula is apt to be the sequel of an operation, 
but may be congenital. If the ureter opens into the intestine 
infection commonly passes up the ureter to the kidney. This 
has been the result of artificially turning the ureters into the rectum 
because in this case there is no valve at the orifice to protect the 
ureter. The urine is generally irritating to the rectal mucosa and 
the patient when constipated feels a desire for defecation and 
passes urine without feces per anum. Cystoscopy shows only one 
ureteral orifice, or one orifice transmitting urine and the other 
functionless. 

NEW GROWTHS OF THE URETER 

Primary tumors of the ureter are rare. E. Garceau (" Renal and 
Ureteral Tumors," 1909) mentions fourteen cases of strictly localized 
primary ureteral tumors which he has analyzed, ureteral calculus 
being associated with two of these. The more usual forms are 
epithelial growths occurring in the varieties of papilloma, and 
papillary and non-papillary epithelioma. 

One or two cases of mesodermal growths have been recorded. 
Ureteral tumors are practically all malignant. They originate 
generally in the upper ureter or in the pelvis of the kidney. Their 
symptoms are pain, hemorrhage, and the presence of a tumor, and 
the diagnosis has been made in only a very few cases without 
operation. The diagnosis may be made, however, in the presence 
of hematuria by isolating characteristic cells of the growth from 
the urine drawn from the pelvis of the kidney by the renal catheter. 



CHAPTER XXVI 

THE DIAGNOSIS OF DISEASES OF THE RECTUM 

Anomalies, p. 494: 1. Arrest or irregular development of the hind gut, 
p. 496; Imperforate rectum, p. 496; Imperforate rectum with outlet into 
the urethra or bladder, p. 496; Imperforate rectum with outlet into the 
vagina, p. 497. 2. Arrest or irregular development of the proctodeum, p. 
497; Imperforate anus, p. 497; Imperforate anus with anal canal ending 
in the vulva, p. 497; Anus well-formed, anal canal ending above in a cul-de- 
sac, p. 497; Abnormally small anus, p. 498. 

Hemorrhoids or Piles: Frequency and etiology, p. 498. External hemor- 
rhoids, p. 500. Internal hemorrhoids, p. 501. 

Fissure in Ano, p. 503: Symptoms, p. 503. Diagnosis, p. 504. Differ- 
ential diagnosis, p. 505. 

Inflammation of the Rectum, Proctitis, p. 505: 1. Simple proctitis, p. 
506; Acute catarrhal proctitis, p. 506; Chronic catarrhal proctitis, p. 507; 
Atrophic proctitis, p. 507; Hypertrophic proctitis, p. 508. 2. Specific 
proctitis, p. 510; Gonorrheal proctitis, p. 510; Syphilis of the rectum and 
anus, p. 510; Congenital syphilis, p. 510; Chancre, p. 511; Mucous patches, 
p. 511; Ulcerations, p. 512; Gummata, p. 512; Syphilitic stricture, p. 512; 
Chancroids of the anus and rectum, p. 512; Tuberculosis of the anus and 
rectum, p. 513; Dysenteric proctitis, p. 513. 

Abscess and Fistula in Ano, p. 514: Abscess, p. 514. Fistula, p. 516: 
Varieties, p. 516; 1. Complete, p. 516; Horseshoe fistula, p. 516; 2. Incom- 
plete, p. 517; Blind external fistula, p. 517; Blind internal fistula, p. 517; 
Symptoms, p. 518; Physical examinations, p. 518. 

Stricture of the Rectum, p. 518: Congenital strictures, p. 519; Strictures 
due to pressure on the rectum from without, p. 519. Inflammatory strictures, 
p. 519; Pathology, p. 519; Symptoms, p. 520; Physical examination, p. 520. 

Prolapse of the Rectum, p. 521 : Symptoms, p. 521. Physical examination, 
p. 522. 

New Growths of the Rectum, p. 522: 1. Benign tumors, p. 522; (a). 
Tumors about the anus, p. 522, Papilloma, p. 522; Soft fibroma, p. 523; 
Lipoma, p. 523. (6). Tumors of the rectum, Polypi, p. 523; Adenoma or 
mucous polyp, p. 523; Fibro-adenoma, p. 523; Lymph-adenoma, p. 523; 
Glandular polypi, p. 524; Fibroma or fibrous polyp, p. 524; Myoma, p. 
524; Villous tumor, p. 524; Myomatous polyp, p. 525. 2. Malignant 
tumors, p. 525; Cancer of the rectum, p. 525; Cancer of the anus, p. 526, 
Pathology, p. 526, Symptoms, p. 527, Diagnosis, p. 528, Differential diag- 
nosis, p. 528; Sarcoma of the rectum, p. 529, Varieties, p. 529, Diagnosis, 
p. 530. 

A short sketch of the chief points in the anatomy and physiology 
of the rectum, as well as a description of the methods of examination, 

494 



ANOMALIES 



495 



will be found in Chapter IX., page 121. An analysis of the chief 
symptoms of rectal disease is given in Chapter X., page 156. 



ANOMALIES 

The different stages of the development of the rectum and anus 
are shown cliagrammatically in the figures from Schroeder on 
page 395, Figs. 158-162, Chapter XXL As it is not the general 
custom for obstetricians to examine carefully the anus and rectum 
of the new-born infant, many minor malformations pass unob- 
served. Where a careful examination is made some degree of mal- 
formation will be found not so infrequently. Starr has estimated 




Fig. 191. — The Anal Canal. A, Columns of Morgagni; B, Semilunar valves 
or Crypts of Morgagni; C, Dentate Border Marking Upper Limits of Anus and 
surmounted by Papillae; D, Hilton's White Line. (Tuttle.) 

that anal and rectal malformation occurs about once in ten thou- 
sand births. It is more common in girls than in boys, if we 
include anus vaginalis (see page 393, Chapter XXI.). As shown in 
the diagrams on page 395 the rectum and the anus are developed 
from entirely different structures of the blastoderm, the former 
from the hind-gut, and the latter from the proctodeum, a depression 
in the epi-blast opposite the lower end of the hind-gut, therefore 
malformation of the one does not necessarily imply abnormality 
of the other. As a matter of fact, if the rectum is malformed 
or displaced the anus is generally normal, and vice versa. 

Malformation of either of these organs is likely to be associated 
with malformation in other portions of the body that are derived 



496 



DISEASES OF THE RECTUM 



from the same layer of the blastoderm. For instance, children 
with anomalies of the rectum are apt to surfer with cleft palate. 

Many of the developmental defects are associated with non- 
viability and monstrosities. The following anomalies have been 
described: 



1. Arrest or Irregular Development of the Hind-gut 

Sir Charles Ball ("The Rectum, Its Diseases and Developmental 
Defects") reports the case of a child three months old, in which 
the rectum was entirely absent, also the entire colon, the ileum 

opening in the center of an ex- 
strophy of the bladder. The 
external genitals were also 
wanting. Children born with 
such defects must necessarily 
be short lived. 

Imperforate Rectum. — This 
is a common malformation, the 
bowel ending in an open tube 
on a level with the reflection of 
the peritoneum on the rectum, 
presumably due to the failure 
of the hind-gut to send out a 
bud, the post-allantoic gut, to 
meet the proctodeum. The 
condition may or may not 
be associated with imperforate 
anus. If it is, the condition is 
recognized at once by inspec- 
tion ; if not, the infant is gener- 
ally dosed with cathartics, and only when grave symptoms of 
obstruction supervene, is a thorough examination made. The 
physician should make it a rule to institute a thorough physical 
examination if an infant's bowels have not moved within the first 
twenty-four hours of life. If the anus appears to be normal ex- 
ternally, introduce the well-anointed tip of the little finger and 
determine whether the anal canal is patent. 
Imperforate Rectum with Outlet into the Urethra or Bladder. — In 




Fig. 192. — Cast of Rectum and Anal 
Canal. (Tuttle, after Quenu and Hart- 
mann.) 



ANOMALIES 497 

this anomaly there has been a persistence of the allantoic opening 
with failure of the rectum to end in the anus. If the opening is 
into the urethra (a condition usually found in the male) there is 
an escape of flatus and meconium from the urethra together with 
the mine; if, on the other hand, the opening is into the bladder the 
meconium and feces become mixed with the urine and sooner or 
later the individual succumbs to ascending infective ureteritis and 
kidney disease, even if the outlet is large enough to obviate intes- 
tinal obstruction. 

Imperforate Rectum with Outlet into the Vagina. — This is a per- 
sistence of the urogenital sinus and is met with not infrequently. 
The opening may occur at any point in the vagina and is generally 
large enough to permit the passage of meconium or even solid feces. 
An imperforate hymen may obstruct the escape of the feces from 
the vagina, and in this case there is present a bulging, greenish 
membrane in the situation of the introitus. 

The rectum has been known to be imperforate and to connect 
with the uterus, and also to open on the back near a spina bifida; 
and the rectum may open normally, but have connected with it 
ureters, uterus, or vagina. Also, diverticula in the lower rectum 
are sometimes found. 

2. Arrest or Irregular Development of the Proctodeum 

Imperforate Anus. — There may be no trace of the anus, or its 
situation may be marked by a slight depression, or by a wart-like 
prominence ; this constitutes entire absence of development of the 
proctodeum. 

Imperforate Anus with Anal Canal Ending in the Vulva. — This is 
a very common anomaly and is confounded with imperforate 
rectum having a vaginal outlet. Women with this anomaly may 
have children and live to an advanced age without realizing that 
they are abnormal, as they may have perfect control over the 
vulvar anus. Incontinence of feces is common in these cases, 
however. 

Anus Well Formed ; Anal Canal Ending above in a Cul-de-sac. — In 

this malformation the proctodeum develops a normal anus, but the 

anal canal is imperforate above. The condition may be associated 

with imperforate rectum, but often the rectum is normal and only 
32 



498 DISEASES OF THE RECTUM 

a membranous septum separates its cavity from the anal canal. 
The child on straining may cause this septum to protrude from 
the anus. 

Abnormally Small Anus. — The anus may be abnormally small 
(see Congenital Stricture of the Rectum, page 519), or it may be 
divided into two parts by a median longitudinal septum. 



HEMORRHOIDS OR PILES 

Hemorrhoids or piles are tumors composed chiefly of dilated 
blood-vessels or blood-clots, situated beneath the mucous membrane 
or skin of the anus or lower rectum. They are (a) external, when 
thej T are on the outside of the anus, either as exaggerations of some 
of the natural rugae of the skin around the anus, or rounded or 
elongated venous tumors situated at the margin of the anus; or, 
they are (b) internal, tumors originating within the anal canal or 
in the ampulla, capable, perhaps, of being forced outside. Both 
sorts of piles may exist in the same patient. Histologically a pile 
is seen to be made up not only of the dilated veins, with thickened 
walls, but also of a considerable amount of connective tissue, the 
latter being more in evidence in cases of long duration. 

The terms hemorrhoids and piles are used interchangeably, but 
the former (from the Greek alfLoppota, a discharge of blood) ap- 
pears to have the better authority, perhaps because it appears 

in the Bible. In 1 Samuel, v. 9, we find: — " the hand of the 

Lord was against the city with a very great destruction; and he 
smote the men of the city, both small and great, and they had 
emerods in their secret parts. " 

The term pile, signifying a ball (from the Latin, pila), would seem 
to be fully as descriptive as hemorrhoid, but having been used 
extensively by the quacks has fallen into disrepute. 

Frequency and Etiology. — The disease is extremely common and 
few persons pass middle life without having suffered from it. It 
appears to be more common among men than women, although 
authors vary in their estimation of the relative frequency. Perhaps 
five men to three women is a fair statement. 

Hemorrhoids are more often found in middle age, although cases 
are on record as young as six months, one author having reported 




1. THROMBOTIC H/EMORRHOiDS 




2. INFLAMED H/EMORRHOIDS WITH EROSION 






3. INTERNAL H/EMORRHOIDS 
WITH CEDEMA OF ANAL MARGIN 4. PROLAPSING INTERNAL HAEMORRHOIDS 



I 



Fig. 193.— Types of Hemorrhoids. (J. P. Tuttle.) 



499 



500 DISEASES OF THE RECTUM 

thirty-nine children under the age of fifteen years who had hemor- 
rhoids. Heredity seems to play a role in the causation, successive 
generations of a family suffering with the disease. The upright 
posture apparently has to do with the causation, for none of the 
domestic animals have hemorrhoids except, occasionally, very 
fat, over-fed dogs. It is supposed that the thin- walled, valveless 
veins of the rectum are unable to stand the constant pressure of a 
blood column of some fourteen inches in height, which they are 
subjected to when the human frame is in the upright position. 

Exciting causes are, overeating, rich food, lack of exercise, and 
sedentary occupations. Violent straining, as in lifting heavy 
weights, or straining at stool, may cause a hemorrhoidal condition 
of the veins of the anus, and thrombotic hemorrhoids are nearly 
always caused in this way. 

Heart disease, kidney disease, and cirrhosis of the liver must be 
classed as exciting causes, but chronic constipation with the passage 
of solid fecal masses along the rectum, stripping the venous blood 
away from the heart, is one of the chief direct causes. Uterine 
diseases are reckoned as causative of piles. Certain it is that the 
two are frequently associated. 

External Hemorrhoids. — There are two varieties of external 
hemorrhoids, (a) redundant folds of the skin about the anal opening, 
and (6) venous tumors, (a) The normal corrugations of the skin 
surrounding the anus may be exaggerated and little tabs of skin 
and connective tissue result. These may be of little significance; 
on the other hand, they are capable of being inflamed, or even 
suppurating and of leaving behind more or less induration. Con- 
stipation is the direct cause. The piles may cause itching and, when 
inflamed, smarting, rendering sitting uncomfortable. If there is 
suppuration, the symptoms are those of abscess. Examination 
shows retained secretion or fecal matter between the rugae and 
the pile will be found to be red, glistening, and perhaps excoriated. 
(b) The superficial veins of the margin of the anus become dilated 
and the condition may involve the entire circumference of the anus. 
The veins belong to the inferior hemorrhoidal plexus. The swelling 
may be limited to one, two, or three circumscribed tumors. In 
any event the swelling is marked during straining efforts and 
almost completely subsides soon after, leaving the skin loose and 
redundant when the straining has ended. There is no induration 



HEMORRHOIDS 501 

or excoriation. The chief complaint is difficulty in defecation and 
also a feeling of fullness at the anus. The patient feels that her 
bowels should be emptied, but she can not accomplish it even by 
persistent straining and there is much soreness lasting after stool. 
In the case of this sort of piles there may be acute attacks of spasm 
of the sphincter attended by great burning and itching, very 
commonly just after the patient has gone to bed at night, or after 
defecation. 

The patient being on her side and relaxed, examination shows 
the skin of the anus loose and redundant and the sphincter tightly 
closed. If the piles are thrombosed there will be small, oval or 
round tumors, varying in size from a pea to a walnut, situated 
just beneath the skin, the color being that of the normal skin, or 
varying from red to dark blue. This is the sort of pile that causes 
sudden symptoms of sharp, cutting pain when the thrombosis 
occurs. 

On straining, the anal orifice forms the apex of a cone-like prom- 
inence, and flatus or a little rectal mucus may escape. When 
the finger is passed through the anus, the sphincter grips it tightly 
and hinders its easy introduction. The sphincters are abnormally 
strong and the rectum is apt to be dilated and contain flatus, or even 
feces. Sometimes a chronic condition of this sort is productive 
of rectocele. 

Internal piles may complicate the external piles and should be 
sought for. 

Many physicians, as well as the laity, assume that all piles origi- 
nate in the rectum and have come down, and therefore urge their 
patients to replace them. Of course, replacement should not be 
attempted unless the piles are internal. 

External piles should be handled gently, it being a mistake to 
squeeze the thrombosed hemorrhoids with the object of forcing 
out the clot, for at any time the tumor may become infected and 
trauma will assist in gaining entrance for the germs. 

Internal Hemorrhoids. — Internal piles consist of a varicose con- 
dition of the veins of the lowest two and a half inches of the rectum. 
Not all of this region is affected in most cases, and the lower part, 
the anal canal, is the place where internal hemorrhoids are most 
often found. The internal pile is apt to be pear-shaped, because 
the vein (a branch of the superior hemorrhoidal plexus) issuing 



502 DISEASES OF THE RECTUM 

from it, passes upward in the submucous tissue and soon loses its 
varicosity, the lower end only being bulbous. Generally there are 
several of these venous tumors placed parallel to one another. 
On dissection, this variety of hemorrhoid consists of a mass of 
dilated veins and connective tissue. In thrombosed piles there is 
a blood clot and more connective tissue. Constipation and heredity 
seem to play the chief roles in the causation. 

The symptoms are hemorrhage and the protrusion of the pile 
through the anus. 

The amount of blood lost may be slight and occur only at stool, 
or it may be excessive and come on at irregular periods. It is 
difficult to judge, from the description of the patient, how much 
blood is lost, and one must always remember that blood lost per 
anum is not necessarily from the rectum, but may come from the 
stomach, duodenum, or ileum. If from the latter situations it will 
be dark colored and tar-like in consistency, whereas if from the 
rectum it will be less dark; it may be arterial and more or less 
mixed with mucus or feces. Generally blood from internal hemor- 
rhoids is passed after stool. 

Protrusion of the hemorrhoid does not come on until after the 
tumor has existed a considerable time and has attained a large 
size. At first the pile recedes spontaneously, but as it gets down 
farther, the sphincter contracts firmly and prevents its return. 
In bad cases, rest in bed, with the hips elevated, may be necessary 
before reduction can be accomplished, but, as a rule, the pile can be 
pushed up after it has been anointed.- 

An excess of mucus is generally associated with internal hemor- 
rhoids and there may be a sense of weight, or aching in the sacral 
region, or even pain in the anus, when the pile is prolapsed. 

Examination shows edema of the skin about the anus in the 
form of one or more soft elastic folds; this swelling is more marked 
if the piles are strangulated and is due to the obstruction of the 
venous return. The patient is asked to strain, and if the piles are 
well developed they come into view as purplish tumors, the anus 
being below its natural position. The finger inserted into the rec- 
tum detects the hemorrhoids as elastic tumors, perhaps pedicled, 
and hard if thrombosed. 

Hemorrhoids of the anterior wall of the rectum may be inspected 
by everting the wall of the rectum, in the case of women who have 



FISSURE IN ANO 503 

had children, by pressure with a finger in the vagina. In virgins, the 
pelvic floor is too rigid to permit of this procedure. The sphincters 
are hypertrophiecl except in long-standing cases, when they do not 
appear to have the normal contractile power. 

By the use of the short proctoscope, piles may be seen as bluish 
tumors projecting from the mucous membrane. 

FISSURE IN ANO 

Anal fissure, or irritable ulcer, signifies a superficial ulcer situated 
in one of the sulei between the folds of the mucosa of the anal canal. 
It is almost always single, it is pear-shaped or triangular in form, is 
always in the long axis of the canal, and varies in length from three- 
eighths to seven-eighths of an inch (9 millimeters to 2.1 centi- 
meters). It is from a quarter of an inch (6 millimeters) to half an 
inch (1.2 centimeters) broad, the wider part being generally below 
and in the skin of the anus. At the lower limit of the fissure, or 
just to one side of it, there is sometimes a small fold of skin called 
"a sentinel pile." 

Fissure is most often found on the posterior surface of the anal 
canal, although it may be on any side. In cases of long standing 
the ulceration may reach in depth to the sphincter muscle; as a 
rule it is superficial. 

The disease occurs in all ages and conditions of life, but is chiefly 
found in adult life and especially in women during the childbearing 
period. 

Constipation is the cause Of fissure; hard, dry, scybalous masses 
tearing the delicate mucous membrane while being voided. 

Symptoms. — The symptoms are pain, muscular spasm, and 
occasional loss of blood. The pain seems to be out of all proportion 
to the size of the lesion and is described as a burning, aching, and 
throbbing sensation just within the anus. It begins while the 
feces are being passed (it may be delayed for half an hour) and 
lasts from half an hour to six or eight hours, to return when the 
next motion of the bowels takes place. The patient is induced to 
put off defecation because of the discomfort and thus the fissure is 
aggravated. The spasm of the sphincter causes great pain and 
also interferes with defecation, besides diminishing the diameter 
of the fecal mass. 



504 



DISEASES OF THE RECTUM 



Diagnosis. — Inspection shows a fissure, when the buttocks are 
widely separated, and the skin of the anus is apt to be redundant 
and thrown into exaggerated folds in these cases. The external 
sphincter is palpated to detect abnormal thickening or induration, 
and when the patient is asked to strain down, the amount of spasm 
of the sphincter may be estimated, the straining causing pain in 
the fissure. Discharge from the fissure, small in amount and 




Fig. 194.— Fissure in Ano. (Tuttle.) 



non-purulent, is to be looked for. Digital exploration of the rectum 
should be made, with an anesthetic if the pain is too severe, prep- 
arations being made at the same time to treat the suspected 
fissure, so that only one anesthetization may be necessary. The 
ulcer is felt as a roughened patch in the smooth mucosa of the anal 
canal. 
If the situation of a fissure can be determined, the finger should 



INFLAMMATION OF THE RECTUM 505 

be pressed against the opposite wall to cause as little pain as 
possible. The spasmodic contraction of the sphincters and leva- 
tores ani is now apparent and feces are apt to be found in the 
rectum. The rectum should be cleared by enema and further ex- 
amination made. The complications of anal fissure, such as polypi, 
piles, and blind internal fistula, are generally situated in the lowest 
part of the rectum. Unless the patient is anesthetized it is not 
wise to pass the proctoscope in the case of fissure, because of the 
great pain caused. 

Differential Diagnosis. — Simple fissure must be differentiated 
from 

Syphilitic Fissure. — The latter are generally multiple and are 
on the right or left of the anus, not in the middle line; they cause 
pain that begins during defecation but does not persist so long as 
in simple fissure and is apt to recur at night. The inguinal or the 
femoral lymphatic glands will be found to be enlarged individually, 
and there is a history of syphilis. 

Blind internal fistula is attended by a history of continuous 
pain, which is accentuated by defecation but does not cease en- 
tirely. It is accompanied by a periodic discharge of pus, with the 
relief of pain, except during defecation. Pus can generally be seen 
issuing from the bowel in cases of blind internal fistula, and the 
finger introduced in the rectum will be found to be streaked with 
pus on its withdrawal, and instead of a roughened patch, as in 
fistula, the ball of the finger feels induration. Perhaps a depression 
can be felt and a bent probe can be passed into the fistula. 



INFLAMMATION OF THE RECTUM— PROCTITIS 

Inflammation of the rectum may be divided into 

1. Simple, those inflammations of unknown bacterial origin, or 

2. Specific, those inflammatory processes due to the bacteria of 
gonorrhea, syphilis, tuberculosis, or dysentery. 

An inflammation affecting the rectum generally involves the 
colon as well, because the two are similar structures anatomi- 
cally and parts of one canal, therefore it is not always possible 
while considering proctitis to rule out colitis. 

The absorptive power of the rectal mucosa is considerable, as 



506 DISEASES OF THE RECTUM 

is attested by the rapidity with which fluids injected into the 
rectum are taken into the circulation. It is here that the fluid 
contents of the intestine are rendered semisolid or solid by the 
abstraction of their watery constituents, therefore it is not surpris- 
ing that the bacteria from the feces, especially if the solid parts 
cause abrasions, should find lodgment in the walls. 

As a matter of fact, the rectum, especially in its lower part, 
seems to be relatively immune to septic infection, just as in the 
case of the lips and mouth and the other openings of the body. 
The inflammatory process may be of mild grade, catarrhal proctitis, 
or it may progress to ulceration, ulcerative proctitis. 

1. Simple Proctitis 

Simple catarrhal inflammation of the rectum is a common 
disease, especially in women who have uterine disease. It may be 
(a) acute, or (b) chronic. 

(a) Acute catarrhal proctitis may be caused by pin-worms, im- 
pacted feces or foreign bodies, or by prolapse of the rectum. Other 
causes are: highly seasoned food: sitting on cold stone, wet seats, or 
the damp ground; irritating cathartics, such as jalap, aloes, 
gamboge, and podophyllin. Fermentation and putrefaction of the 
intestinal contents may be direct causes of acute proctitis. 

Symptoms. — The symptoms are a sense of discomfort and fullness 
in the region of the rectum, with tenesmus, and the forcible ejection 
of fluid feces through an anus made small by irritation of the 
sphincter. There may be pain in the pelvis, radiating into the back 
and thighs. The patient has less discomfort while lying down 
than when erect and there may be slight fever. 

Frequent desire for an evacuation of the bowels is a prominent 
symptom from the first, and defecation does not remove the desire, 
the straining even causing prolapse of the rectum sometimes in 
children. 

The discharges are fluid and after the first twenty-four hours 
may be tinged with blood or pus. The process is confined to the 
mucosa, as a rule, in acute proctitis, though the inflammation may 
be so severe that portions of the mucous membrane are cast off 
and the deeper layers affected also. In the latter event, ulceration, 
abscess, fistula, or stricture may follow. 



INFLAMMATION OF THE RECTUM 507 

Examination shows great tenderness when an attempt is made to 
introduce the ringer or speculum into the rectum and the sphincter 
is contracted. The mucous membrane feels hot, dry, and swollen 
in the very early stages, and later very moist. Through the proc- 
toscope, at first, it is of a light red color throughout, or deep red in 
patches and lighter red elsewhere; later, the color is darker red 
and the surface is covered in places with opaque yellowish mucus. 
Slight trauma, even from wiping away the secretions, causes 
bleeding. 

(b) Chronic catarrhal proctitis may follow acute catarrhal inflamma- 
tion of the rectum, or, as far as we know, it may be chronic from 
the beginning. The latter is true of atrophic catarrhal proctitis, 
the most frequent type of catarrhal proctitis. Hypertrophic catar- 
rhal proctitis, the other form, although generally chronic in course, 
may show an acute stage. 

Atrophic Proctitis. — This consists of an atrophy of the mucous 
membrane and its glandular elements throughout the rectum. 
It is limited to the rectum; not, like the hypertrophic variety, 
affecting the colon also. The disease is found mostly in adult life 
and is probably due to sedentary occupation, the overeating of 
highly spiced food, chronic constipation, and the abuse of cathartics 
and enemata. The affection is not infrequently associated with 
syphilis, either acquired or hereditary. Sometimes it is associated 
with chronic pelvic inflammation. J. P. Tuttle has noted the 
association of this form of rectal catarrh with chronic catarrh of the 
nose, and C. B. Kelsey calls attention to the frequency with which 
gynecologists overlook this disease and the possibility, if an ulcer- 
ative stage has been reached, of its causing subsequent stricture 
of the rectum. 

Pathological examination of the tissues of a rectum affected by 
chronic atrophic proctitis shows the mucosa to be granular, dry, 
inelastic, and adhering to it small masses of dry feces and perhaps 
shreds of exfoliated epithelium. Under the microscope the epithe- 
lium is found wanting in many places on the surface and there are 
granulations and ulcerated areas. The crypts of Lieberkiahn are 
atrophied, the solitary follicles are enlarged and distended, and 
the connective tissue of the submucosa is increased in amount. 

The symptoms are those of a mild irritation of the rectum. As 
the disease is apt to be complicated by fissure and hemorrhoids, 



508 DISEASES OF THE RECTUM 

the symptoms are more directly caused by these affections. Long- 
continued constipation, with hard and lumpy stools and burning 
and discomfort in the rectum, may be the only symptoms, the 
latter being often mistaken for chronic disease of the ovaries or 
tubes. Pruritus ani is a common symptom. 

Examination shows the skin of the anus relatively normal, and 
the mucous membrane of the rectum bright red and shiny, with 
small pieces of dry feces adhering to it in places. It does not bulge 
into the end of the proctoscope. To the examining finger, the 
mucosa feels dry and it sticks to the finger. In long-standing 
cases the rugae seem to be obliterated and the valves of Houston 
stand out more prominently, while the ampulla is dilated. Erosion 
and ulceration are not uncommon. In such cases the stools may 
be smeared with blood or pus, and the eroded or ulcerated areas 
may be seen through the proctoscope. 

Hypertrophic Proctitis. — This is a chronic inflammation of the 
rectal mucous membrane, in which the mucosa and submucosa 
are thickened. The disease involves the colon as well as the rectum, 
being a part of an inflammatory process affecting the entire large 
intestine, and it generally follows an acute attack of proctitis or 
colitis. The affection is found most often in fat, flabby individuals 
who are the victims of chronic constipation, and occurs also in cases 
of chronic catarrhal appendicitis, uterine malpositions, abdominal 
tumors pressing on the intestine, and in movable kidneys, which 
slide up and down on the bowel. 

Pathological examination of the rectal wall shows marked 
hypertrophy of all the elements of which it is composed, including 
the glands and the connective tissue of the mucosa and submucosa. 

The symptoms are apt to be more general than local. Where 
the disease follows a well-marked acute attack, there will be a lessen- 
ing in the severity of the symptoms. As chronic hypertrophic 
proctitis is a part of a colitis and a large area of intestine is involved, 
the symptoms are of more serious moment than is the case in atro- 
phic proctitis. They are: diarrhea alternating with constipation, 
the stools being soft and mixed with pus, or hard and round, like 
sheep-droppings, and covered with muco-pus. Tenderness on pres- 
sure over the course of the colon in the abdomen, with swelling of 
the abdomen and griping pains, may be a feature of the case. In 
cases of a pronounced character, there may be tenesmus, occurring 



INFLAMMATION OF THE RECTUM 509 

periodically and accompanied by the discharge of a large quantity 
of thick glairy mucus or muco-pus. Mucus may escape invol- 
untarily in these cases to such an extent that the patient is forced 
to wear a napkin. Pruritus is a common and a troublesome symp- 
tom. Constitutional symptoms are: flatulence, loss of appetite, 
coated tongue, yellow skin, offensive breath, and loss of weight and 
strength. 

Examination shows redness of the skin and hypertrophy of 
the rugae about the anus due to the irritation caused by abundant 
mucus coming from the anus. Dermatitis may exist in extreme 
cases, with much thickening of the skin. Condylomata acuminata, 
with their characteristic tree-like growth, are not uncommon in 
the skin about the anus. 

By digital examination, the mucous membrane of the rectum 
feels doughy, and the cavity of the gut seems somewhat restricted; 
quite the opposite to the state of the case in atrophic proctitis. 

Through the proctoscope, the flabby redundant mucosa bulges 
into the end of the proctoscope. It is pale red in color and covered 
with muco-pus. It does not bleed easily and neither ulceration, 
hemorrhoids, nor fissure is apt to complicate this form of proctitis, 
although prolapse may. 

The following table shows the principal points in the differential 
diagnosis between the atrophic and the hypertrophic forms of 
proctitis : — 

Chronic Atrophic Proctitis Chronic Hypertrophic 

Proctitis 

1. Constipation is generally the 1. Constipation alternating with 

rule. diarrhea. 

2. Secretions absent; peri-anal 2. Secretions increased about the 
skin dry and relatively nor- peri-anal region; acute der- 
mal, matitis ; moist eczema. Con- 
dylomata apt to be present. 

3. Sphincters usually contracted 3. Sphincters generally relaxed. 

and hypertrophied. 

4. Mucous membrane dry, stools 4. Mucous membrane swollen 

adhesive, rectum readily dis- and edematous, prolapses 

tended and easy to examine. over the end of the procto- 

scope during examination. 



510 DISEASES OF THE RECTUM 

Chronic Hypertrophic Chronic Atrophic Proctitis 

Proctitis 

{continued) {continued) 

5. Mucous membrane bleeds 5. Bleeding from the mucous 
readily; light sponging pro- membrane uncommon, 
duces considerable oozing. 

6. Mucous membrane dry and of 6. Mucous membrane moist and 

a bright red color. of a pale red or pinkish hue. 

7. Ulceration common. 7. Ulceration rare. 

8. Inflammatory process almost 8. Inflammatory process rarely 
invariably confined to the limited to the rectum and 
rectum and sigmoid. sigmoid, the colon being in- 
volved as well. 

9. Hemorrhoids often present. 9. Hemorrhoids an unusual com- 
Prolapse seldom seen. plication. Prolapse more fre- 
quent. 

2. Specific Proctitis 

Gonorrheal Proctitis. — This disease is rarely diagnosed, though it 
probably is not so infrequent as formerly supposed by writers on 
venereal disease. It is undoubtedly more frequent in women than in 
men and is due to the extension of the disease from the vulva be- 
cause of the introduction of the gonococcus on the finger or rectal 
tube, or it may be due to unnatural intercourse. The symptoms 
and anatomical appearances are those of simple proctitis and the 
diagnosis is made by the isolation of the gonococcus from the 
discharges. 

Condylomata, fissure, and submucous fistula are found as 
complications. 

Syphilis of the Rectum and Anus. — Syphilis manifests itself in the 
skin about the anus, in the anal canal, and in the rectum proper, 
in primary, secondary, and tertiary lesions. It may be congenital, 
or it may be acquired innocently, or by inoculation by unnatural 
coitus. 

Congenital syphilis is almost always of the secondary type and 
occurs in young children, usually during the first two or three 
months of life. The lesions consist either of cracks in the skin 
about the anus, radiating from the anus, or smooth, flat, elevated 



INFLAMMATION OF THE RECTUM 511 

patches, from a quarter of an inch to half an inch in diameter, in 
the same situation. These lesions exude a very contagious discharge. 
The diagnosis is established by finding the Spirochseta pallida in 
the discharge or scrapings from the lesions, and in the appearance 
of syphilitic lesions elsewhere in the body. 

As indicating the relative frequency of the different syphilitic 
lesions, the statistics of P. Sick, from the Hamburg General Hospital, 
may be quoted. Among 11,826 women and children treated there 
for venereal diseases, there were: mucous patches, 986; chancroids 
of the anus, 224 ; chancres of the anus, 12 ; strictures of the rectum, 
10; rectal gummata, 2; and anal gumma, 1. 

Chancre, the initial lesion of syphilis, is not uncommonly found 
about the anus in women. Statistics have been published that go 
to show that among women who have syphilis chancre is found 
at the anus in about one in thirteen. The characteristics of the 
chancre in the skin about the anus are exactly the same as on the 
vulva. (See page 406.) 

If the chancre is in the anal canal, or rectum proper, a rare 
occurrence, it is apt to escape detection. Digital and visual ex- 
amination will detect a single, non-sensitive lesion, with an indu- 
rated base, and the individual glands in the groin will be found 
enlarged. Scrapings from the chancre will show the Spirochseta 
pallida. 

Mucous Patches. — The anus is the most frequent seat of mucous 
patches next to the mouth and throat; they may begin on the vulva 
and spread to the anal regions. Mucous patches do not occur within 
the rectum, so far as known. They begin as a reddening of the 
skin between the folds of the buttocks, noticed sometimes before 
the initial lesion has healed; the chancre, in fact, merging into a 
mucous patch. As a rule the mucous patch is developed with the 
secondary lesions, at the same time as the macular eruption upon 
the skin of the rest of the body. The reddened area of skin is raised 
a little above the surrounding skin; the epithelium becomes 
macerated and is shed, leaving a shallow erosion. There is a scanty, 
thin discharge and there is no itching. Soon the surface of the 
erosion is covered by a grayish-white membrane slightly elevated 
above the surface of the skin. The patches vary in size and may 
be single, multiple, or coalescing, so that the entire circumference 
of the anus is involved. 



512 DISEASES OF THE RECTUM 

When the papillae of the mucous patches grow upward from the 
skin they may form flattened warty growths called condylomata 
lata, or vegetating mucous patches. They are accompanied by more 
or less discharge and are more commonly found in uncleanly 
syphilitics. 

Ulcerations may result from the breaking down of mucous patches. 
Syphilitic ulcerations within the rectum are common. They present 
few symptoms and reach the chronic stage before they are recog- 
nized. They tend to spread, following the course of the blood-vessels 
and the lymphatics and are destructive in their tendencies, having 
been known to perforate the peritoneum. The lymphatic glands 
in the hollow of the sacrum become enlarged and may be palpated, 
but must not be mistaken for gummata. 

When the ulcers cicatrize they leave behind them bluish-white, 
non-elastic tissue that forms a stricture. 

Gummata. — Gummata of the anus are very rare and only a few 
cases of gumma of the rectum have been reported. The latter is 
described as a round, elastic, painless tumor, situated in the sub- 
mucous tissues. It is single or multiple and from the size of a pea 
to that of a small orange. The fact that a gumma does not sup- 
purate, is not tender, and does not occur in chains, serves to dis- 
tinguish it from enlarged lymphatic glands. 

Syphilitic stricture of the rectum is considered under Stricture, 
page 519. 

Chancroids of the Anus and Rectum. — This affection is rare in 
America, though not infrequent on the Continent abroad. The 
chancroidal ulcer, being auto-inoculable, often extends from 
the vulva (see page 406), therefore we may regard chancroids 
of the anus as secondary in a vast majority of cases. Chancroids 
of the rectum are generally due to sodomy. The points of diagnosis 
and differential diagnosis of chancroids will be found in the chapter 
on diseases of the vulva, page 415. There is a form of chancroid 
called phagedenic, characterized by an intense inflammatory process 
involving the deeper structures, with much destruction of tissue. 
This sort, if situated in the rectum, may cause stricture. It is rare, 
and occurs commonly in patients of debilitated constitution. 

Chancroids and chancre may coexist in the same patient, there- 
fore the physician must be on the watch for the characteristic 
appearance of each lesion. 



INFLAMMATION OF THE RECTUM 513 

Tuberculosis of the Anus and Rectum. — Primary tuberculosis of 
the anus and rectum is extremely rare; the secondary affection, 
occurring in patients with advanced tuberculosis of the lungs or 
other organs, is not infrequent. 

A miliary variety of primary tuberculosis in the skin about the 
anus has been described. In this form there are minute, shot-like 
bodies beneath the epidermis, that have developed in the sweat 
and oil glands of the skin. They are arranged in a crescentic or 
circular shape and soon break down to form shallow ulcers with 
ragged, indurated edges and giving forth a thin discharge of sero- 
pus. 

An ulcerative variety is the common form in which tuberculosis is 
seen, both in the skin about the anus and inside the anal canal. 
The ulcerations are apt to involve both the anal margin and the 
mucous membrane inside the anal canal. They may be single, 
or on both sides of the anus; they are round or oval in shape, the 
borders are irregular in form, but undermined, and of a pale 
color, shading to the normal pink of the surrounding skin. There 
is induration around the ulcer, but the base is relatively soft, 
irregular in its surface, grayish in color, and the granulations do 
not bleed easily. Yellowish tubercles, the size of a millet seed, 
are scattered over its surface, and in the older parts of the base of 
the ulcer cheesy material may be found. The discharge is small 
in amount, sero-purulent, and mixed with blood. 

These ulcerations are not especially painful: they do not tend 
to heal as they progress in all directions and do not, like other 
ulcers, assume the type of fissure when they invade the anal canal, 
but involve both the rugae and the sulci. 

Primary tuberculosis of the rectum proper is practically unknown, 
but the secondary type occurs. The ulcerations present the same 
appearance as in the anal canal, ulcerations here producing 
stricture as their late results. 

The diagnosis is made by finding tubercle bacilli in scrapings 
made from the ulcer and by the characteristics of the ulcer itself. 

Dysenteric Proctitis. — This is an inflammation of the rectum 

and sigmoid flexure of the colon occurring in sporadic dysentery, 

and caused by the ameba coli. In endemic and epidemic dysentery 

the entire colon and rectum are involved, but in this event the 

constitutional disease overshadows the affection of the rectum. 
33 



514 DISEASES OF THE RECTUM 

The inflammation of the rectum is generally of the catarrhal 
variety, but in chronic cases progresses to an ulcerative stage, the 
ulcerations being linear, punched-out, and like little grooves in the 
mucous membrane following the course of the blood-vessels. The 
purulent discharge is very profuse and the submucosa is destroyed 
to a greater extent than the mucosa, whence the undermined edges 
of the ulcers. 

The symptoms of the acute stages of dysenteric proctitis are 
pain and heat in the pelvis and anal region, tenesmus, diarrhea, 
slight elevation of temperature, rapid pulse, and exhaustion. The 
diarrhea is attended by the frequent painful passage of, at first, 
partly solid and partly fluid stools, changing to watery stools and 
finally mucus, tinged with blood and pus. There is burning after 
stool and the frequency of defecation is very great. In the chronic 
stages the frequency is not so great and the symptoms are those 
of ulceration. The ulcers have the characteristic appearances of 
worm-tracks in wood, following the course of the blood-vessels. 
They sometimes result in stricture. 



ABSCESS AND FISTULA IN ANO 

Abscess. — The tissues immediately surrounding the anus and 
rectum are especially subject to infection and inflammation, because 
of the abundant lymphatic and blood supply of the parts, from the 
ample source of bacteria in the retained contents of the intestine, 
and from the obstruction to the circulation caused by hardened 
fecal masses. 

The bacteria most frequently found in abscesses about the 
rectum are the tubercle bacillus, and bacterium coli communis, 
generally associated with staphylococcus or streptococcus. 

The course of the abscesses is acute or chronic, only the deeper 
ones, the superior pelvi-rectal abscesses, being of severe grade and 
immediately dangerous to life. Abscesses in this region burrow 
in the path of least resistance, passing between the fascial planes 
and around the blood-vessels which are large enough and vigorous 
enough to resist thrombosis and gangrene. 

Superficial abscesses, of the nature of acne pustules or furuncles, 
open on the skin; subcutaneous abscesses and deeper seated 



ABSCESS 



515 



suppurations, generally, besides opening through the skin, make 
their way between the internal and external sphincters, perforate 
the mucous membrane, and discharge into the anal canal, forming, 
in a large majority of cases, a fistula. 

Those that enter the bowel alone form blind, internal fistula?, 
while those that open both on the skin and into the gut are complete 
fistula?. 

The different sorts of abscesses in this region as enumerated by 
Goodsall and Miles ( " Diseases of the Rectum," Part I.) are: — (a) 
subcutaneous, (6) ischio-rectal, (c) submucous, (d) pelvi-rectal, 

--A?i/cous membra ft c 
Submucous T/'ssuff 
^Circular musclefi'bres 

■Long-iTudinal muscle fibres, 
pelv/'-reclal space. 

Levator an!. 



The internal Sphincter. 

Interval between the internal 
anof the external sphincters 

Superficial portion of the _„- 
external sphincter. " 




Deep portion of the etlernal Sphincter. 



— Integument 
Tendinous inserti'oq of the 

longitudinal muscle fibres 



Fig. 195. — Diagrammatic Representation of the Lower part of the Rectum 
and its Immediate Surroundings. (After Goodsall and Miles.) 



(e) labial. As has been said, the (b) ischio-rectal abscess opens not 
only on the skin, but also between the sphincters into the bowel. 

The (c) submucous abscess originates in the submucous tissue, 
usually in the lowest three inches of the rectum, and is generally 
confined to one side of the bowel. It shows a tendency to burrow 
downward and to empty near the anus. The (d) pelvi-rectal abscess 
begins in the loose connective tissue between the levatores ani 
below, and the reflection of the peritoneum above. This space being 
continuous with the bases of the broad ligaments, septic inflamma- 
tory processes starting in these structures may spread to the 
pelvi-rectal space. Infection may come from the rectum, from 
malignant disease of th( 4 bowel, or ulcerations high tip. Rarely, 
in the acute form of this disease, the pus may rupture through the 



516 DISEASES OF THE RECTUM 

peritoneum into the abdominal cavity; in the chronic forms it is 
more apt to perforate the levators and form an ischio- rectal abscess. 
This sort of abscess is the cause of deep horseshoe fistula. The 
disease is generally attended by extensive cellulitis, (e) Labial 
abscess is an extension backward to the anal region of a vulvo- 
vaginal abscess. This is a rare sort of abscess. 

The symptoms of abscess are pain in the rectum, with aching and 
throbbing especially on defecation, tenderness in the region of the 
anus, and constitutional symptoms in the acute stages. Exami- 
nation shows great heat, tenderness, and induration of the tissues, 
with fluctuation at the seat of the abscess. The exact situation is 
determined almost entirely by palpation and the physician will 
search for the different sorts of abscesses according to the descrip- 
tions just given. 

Fistula. — The word fistula is derived from the Latin fistula, 
something capable of being split, a hollow reed or pipe. Fistula 
in ano may be defined as an unobliterated abscess track which 
opens either in the skin near the anus, or into the rectum, or both. 
Fistula is comparatively rare in women, the average age at which 
it occurs being thirty-six years. It may be caused by a fissure, by 
ulceration of the bowel, by stricture, by polypoid growths, or by 
carcinoma. 

As implied by the definition, an abscess always precedes a fistula, 
except in the very rare cases of fistula caused by traumatism. 
A fistula generally opens by one orifice in the bowel, but by several 
in the skin. 

Varieties. — There are three sorts of fistula?, although all three 
may be combined in the same patient. They are (1) complete, 
when there is an opening through the skin and also an opening into 
the bowel, and (2) incomplete, including (a), blind external, when 
there is an opening into the skin alone, and (6), blind internal, 
when the only opening is into the rectum. 

1. In the complete fistula the main track generally passes between 
the two sphincters into the rectum, but it may be subcutaneous 
throughout, and not go round the external sphincter. 

From the main track branches go off to end in blind passages or to 
perforate the skin. Rarely the main sinus, after burrowing between 
the" sphincters toward the mucous membrane of the rectum, may 
ascend above the internal sphincter before perforating into the 



FISTULA 



517 



rectum, but as a rule the internal opening is in the anal canal 
between the sphincters. Complete fistulse form about seventy 
per cent of all fistulse. 
2. Of incomplete fistulce (a), the blind external fistula is an abscess 




Complete fistula.- 



Fig. 196. — Diagram of Complete Fistula in Ano. 

cavity having an opening in the skin, near the anus. The track 
may represent a previous existing complete fistula the internal open- 
ing of which has closed. In the case of (6), the blind internal 
fistula, there are three courses taken by the abscess track to its 
opening into the bowel: it may be subcutaneous and pass outside 




jfth'ncl internal 
fistula. 



Fig. 196a.— Diagram of Blind Internal Fistula. 

the external sphincter into the anus; it may be submuscular, passing 
through the external sphincter, or between the internal and the 
external sphincters; or it may be submucous, coursing entirely in 
the submucous tissue. The last form is often due to a preexisting 



518 DISEASES OF THE RECTUM 

fissure, is apt to be higher in the rectum than the others, and may be 
felt by a finger in the rectum as a cord, running in the rectal wall. 

Goodsall and Miles have observed that fistulas which have 
started posterior to a transverse line drawn through the anus, bur- 
row more extensively than those that have started in front of 
this line. 

Symptoms of Fistula. — The symptoms of fistula are pus from 
the bowel, together with the history of a preexisting abscess, or 
fissure, or other rectal disease. Flatus may escape from a complete 
fistula and also liquid feces and gas may distend a blind fistula so 
that it is painful. If the swelling due to inflation is of considerable 
size it is possible to obtain tympany on percussion. The pain of 
fistula is inconsiderable and bleeding is only an occasional symptom. 

Physical Examination. — Examination will reveal the presence 
of an external or an internal opening, or both; the course and 
ramifications of the track of the fistula, and the presence, or absence, 
of complicating diseases. 

If the abscess preceding the fistula has been opened, the opening 
in the skin is apt to be smaller than when the abscess has opened 
spontaneously. All the openings should be investigated thor- 
oughly with a probe. The internal opening is found by proctoscopy 
and by passing a probe into it through the proctoscope. Palpation 
and the passage of the probe are the main reliances of diagnosis. 
Internal piles are the commonest local complication of fistulse; 
fissure, ulcer, stricture, polypi, or carcinoma may also coexist. 

If there is suspicion that a fistula is tuberculous, scrapings of tis- 
sue should be examined for the tubercle bacillus rather than rely on 
evidences of tuberculosis elsewhere in the body. A tuberculous 
fistula has generally a discharge that is small in quantity and thin 
and white, and the fistula is surrounded by much induration. 



STRICTURE OF THE RECTUM 

Strictures of the rectum may be classified, according to their 
causation, as congenital, as due to pressure on the rectum from 
without, or as inflammatory. Obstruction of the lumen of the 
rectum by new growths of the rectum or by foreign bodies in the 
gut may be disregarded in a discussion of stricture, as may the 



STRICTURE OF THE RECTUM 519 

so-called spasmodic stricture, which was formerly thought to be 
very prevalent, but is now regarded by writers on diseases of the 
rectum as a rare curiosity and a temporary condition. Strictures 
may be further classified, according to their form, as annular, or 
as tubular. 

Congenital strictures are generally found in the anal canal, either 
at the margin of the anus or just below the level of the internal 
sphincter. The condition of stricture is apt to be regarded as simple 
constipation and the patient does not consult the physician until 
puberty or after. There is no history of an inflammatory or ul- 
cerative process of the rectum and a careful sifting of the evidence 
shows only a gradually increasing constipation. The stricture may 
consist of a band, or of a circular membrane with an opening in the 
center, being entirely distinct from the sphincter muscle, which 
may, or may not, be hypertrophied. Congenital hypertrophy of 
Houston's valves may constitute a virtual stricture. 

Strictures due to pressure on the rectum from without are relatively 
common in women, as in the retroversion of an enlarged or gravid 
uterus, or a tumor wedged in the pelvis, or a pelvic inflammatory 
exudate. The rectum is surprisingly tolerant of interference of 
this sort and, beyond a constipation and a mild proctitis, there 
may be no evidences that the caliber of the bowel is very nearly 
shut off. As a rule the symptoms due to the encroaching body 
overshadow those due to obstruction of the rectum. 

Inflammatory Strictures. — These constitute a majority of all 
strictures and are due to tuberculous ulceration, to syphilitic ulcera- 
tion, and to ulceration of unknown origin. Most of them are situated 
not higher than two and a half inches (6 centimeters) from the 
margin of the anus. Occasionally a stricture of this sort is found 
as high as three and a half inches (9 centimeters) up the bowel. 

Pathology of Inflammatory Strictures. — Ulceration of the mucous 
membrane is the macroscopic appearance in the early stages of 
inflammatory stricture. When the ulceration has healed there is 
a lack of elasticity of the rectal wall and it has a dry, leathery feel 
and a dull, non-shining appearance. Often the ulcerative process 
continues after the stricture has been formed, and in this case the 
rectum contains muco-purulent discharge. If cicatrization has 
taken place, the cicatrix appears as a bluish-white, dense, liga- 
mentous structure. The ulcer is of the type of infection causing it; 



520 DISEASES OF THE RECTUM 

that is, syphilitic, tuberculous, or simple. Syphilitic ulceration is 
apt to heal below, while, at the same time, it extends upward. 
Gummata may be found in the course of the arteries and veins, 
together with endarteritis. In the tuberculous stricture, the entire 
epithelial surface of the mucous membrane is destroyed and caseous 
nodules are found in the tissues of the submucosa. 

Symptoms of Inflammatory Strictures. — The symptoms of stricture 
during the ulcerative stage are dull, constant pain in the region of 
the rectum, diarrhea, tenesmus, and the discharge of mucus, pus, 
and blood; during the obstructive stage they are, increased fre- 
quency in a desire for an action of the bowels, the passing of small 
quantities of feces with incomplete relief, and, after an interval 
of a few minutes, the repetition of the desire for defecation. As 
the stricture becomes smaller in caliber the feces are passed in 
small-sized, round, or flattened pieces, and, if ulceration is still 
present, pus or blood may streak the stools. 

In the case of strictures of long standing the large intestine 
becomes chronically distended because of insufficient emptying, 
and, as a result, the abdomen is distended. The patient complains 
of distention and of flatulence, more particularly during the first 
two hours after taking food. Another symptom in these cases is 
swelling of the feet and legs, particularly on the left side, and, in 
extreme cases, emaciation, with cachexia from autointoxication, 
result. 

Physical Examination. — Physical examination shows the anus 
to be normal in appearance, except that there may be present 
several folds of redundant skin, or scars, if the patient has suffered 
with complicating fistula. If the stricture happens to be at the 
anal orifice, the natural rugae are absent and there is no redundancy, 
while cicatricial tissue takes the place of some of the skin at the 
anal margin. Straining on the part of the patient produces bulging, 
but no relaxation of the anus, and the finger feels a rigid ring about 
the opening. In the case of stricture within the rectum, the finger 
introduced into the rectum notes deficient contractile power of 
both sphincter muscles. The stricture, as has been said, is generally 
in the lowest two and a half inches of the gut. If the finger tip 
will pass through the stricture, the caliber and the shape and 
length of the stricture may be estimated; if not, the finger in the 
vagina will estimate the length of the inflammatory or cicatricial 



PROLAPSE OF THE RECTUM 521 

mass. The short proctoscope passed through the anus permits 
a view of the stricture, and its size and length may be determined 
by passing through it olive-pointed bougies. Sometimes a smaller 
proctoscope, or a large Kelly cystoscope, may be passed through 
the stricture and a view of the rectum beyond the stricture thus 
obtained. The presence of much thickening about the rectum, 
with the escape of pus on digital examination, generally indicates 
the coexistence of an ischio-rectal or pelvi-rectal abscess. 

In making the diagnosis, the history should be inquired into 
minutely and search made for the stigmata of syphilis or tubercu- 
losis, the two most common causes of stricture. 



PROLAPSE OF THE RECTUM 

By prolapse of the rectum is meant the eversion of a part or the 
whole of the rectum through the anal orifice. It is partial when the 
mucous membrane alone is everted, and complete when all the 
coats of the rectum are involved. The disease is found most fre- 
quently in young children and in old women, especially in the 
women who have suffered from weakening of the sphincter ani 
muscle from childbearing. Laxity of the connections of the 
mucosa with its underlying structures and weakening of the tone 
of the sphincter muscle are predisposing causes. Exciting causes 
are obstinate constipation and chronic diarrhea, causing prolonged 
and repeated straining at stool, also extruded rectal polypi, or 
other rental tumors, causing overstretching and relaxation of the 
sphincters. 

Symptoms. — The symptoms are (a) loss of control over the 
bowels with the involuntary escape of rectal mucus as well as 
flatus and feces; (b) protrusion of the bowel, at first at stool only, 
followed by spontaneous reposition, then protrusion on coughing, 
or any sort of straining, and, finally, permanent prolapse unless 
reduced manually; (c) increased frequency in the action of the 
bowels; (d) pain of moderate or small amount as a result of long- 
continued irritation — pain is of an aching or throbbing character 
and persists as long as the part is protruded; (e) hemorrhage when 
the prolapsed mucous membrane is excoriated or ulcerated, not 
of large amount in any case. 



522 DISEASES OF THE RECTUM 

Physical Examination. — The prolapse may involve the entire 
circumference of the rectum or only a part of it. There is no 
redundant skin about the anus in these cases and palpation deter- 
mines that the mucosa moves freely on the muscular coat: the 
sphincters are relaxed and deficient in contractile power. The 
determination of the thickness of the wall of the prolapsed mass 
shows whether only the mucous membrane or the entire rectal wall 
is down. If the mucosa alone is extruded — incomplete prolapse — 
• the mass is seldom more than two inches long, and one side is gen- 
erally longer than the other. In complete prolapse the protrusion 
is generally equal on all sides and the mass measures some three 
or four inches in length. In incomplete prolapse, the opening into 
the lumen of the gut is circular, or oval, and centrally situated, 
whereas in complete prolapse the opening is slit-like and points 
backward because of the traction of the meso-rectum. In incom- 
plete prolapse these are generally sulci anteriorly and posteriorly 
and the mucous membrane is smooth, whereas in complete prolapse 
there are no sulci and the mucous membrane is marked by several 
concentric furrows. 

NEW GROWTHS OF THE RECTUM 

New growths of the rectum are:* — (1) benign, or (2) malignant. 

1. Benign Tumors of the Rectum and Anus 

Benign tumors are of infrequent occurrence, are of slow growth, 
they do not infiltrate the surrounding structures, and, when re- 
moved, do not show a tendency to recur. They may be divided into : 
(a) tumors about the anus, and (b) tumors of the rectum. 

a. Benign Tumors about the Anus 

These are papilloma, soft fibroma, and lipoma. They arise from 
the skin and subcutaneous tissue. 

Papilloma. — Papilloma is due to hypertrophy of the papillary 
layer of the true skin. It occurs in young adults and appears to be 
due to want of cleanliness. The tumor consists of an enlarged papilla 
in the form of a bulb-shaped tumor about half an inch or three- 
quarters of an inch long, at the margin of the anus. Several tumors 



NEW GROWTHS OF THE RECTUM 523 

are generally present in the same case and the pedicle of each is 
separated from its fellow by a strip of normal skin. Each tumor 
is made up of a central artery and vein in a connective-tissue 
stroma, which is covered by stratified epithelium. The surface of 
the papilloma is the same color as the surrounding skin, though it 
may become eroded and ulcerated. These simple tumors must 
be differentiated from carcinoma. In the latter there is no normal 
skin between the different parts of the tumor, and there is much 
infiltration of the surrounding skin and subcutaneous tissues. 
Condylomata lata have the appearances described on page 512 
and condylomata acuminata those to be found on page 407. Hem- 
orrhoids are of a deep purple color, and are soft and compressible, 
or, if thrombosed, very hard. 

Soft Fibroma. — Soft fibroma is a pedunculated tumor of rare 
occurrence arising from the connective tissue of the submucosa. It 
contains besides connective tissue, muscular and glandular tissue, 
and is similar in structure to molluscum fibrosum. The tumor may 
attain great size and may weigh as much as a pound or more. 

Lipoma. — Lipoma is a fatty tumor caused by hypertrophy of 
one or more lobules of fat. It is situated under the skin surrounding 
the anus, is soft, and is freely movable, in this respect being dis- 
tinguishable from an inflammatory exudate or abscess. Occasionally 
a lipoma is pedunculated. 

b. Benign Tumors of the Rectum — Polypi 

These tumors originating in the rectum are generally pedunculated 
growths and therefore are classed as polypi. They are of the 
following pathological varieties: adenoma, fibroma, myoma, 
villous tumor, myxoma, and lipoma. 

Adenoma. — Adenoma or mucous polyp is the most common form 
and is met with almost entirely in children under ten years of age. 
It consists of a hypertrophy of the crypts of Lieberktihn, and 
shows on section the tubules lined with columnar epithelium and 
surrounded by areolar tissue. If the connective-tissue elements 
predominate the tumor becomes a fibro-adenonia. Lymphoid 
tissue may form the basis of a tumor of this sort, due to hyper- 
trophy of one of the solitary follicles of the rectum, and in this 
case the tumor is a lymphadenoma. 



524 DISEASES OF THE RECTUM 

Glandular polypi are usually single, vary in size from a quarter of 
an inch to one inch in diameter, are round, and attached to the rectal 
wall by a long and slender pedicle. They generally arise in the lowest 
two inches of the rectum and may exist for a long time before the 
pedicle becomes enough elongated so that the tumor is passed 
through the anus at defecation. When it is, the diagnosis may be 
made. The probability is that many of these growths are torn from 
their pedicles and extruded during a movement of the bowels. 
The symptoms are hemorrhage from the anus after the growth 
has gotten within the grasp of the sphincters, and straining. The 
passage of blood from the rectum, in children, should always lead 
the physician to make a rectal examination. The examining finger 
is swept around the rectum and search made for the pedicle of the 
tumor. A view of the rectum and the tumor may be obtained 
through a Kelly proctoscope, No. 12. To make an accurate diag- 
nosis an anesthetic will generally be necessary. 

Fibroma or Fibrous Polyp. — A fibrous polyp is generally situated 
in the lowest two inches of the rectum ; it is from a quarter of an 
inch to an inch in diameter, and is attached to the rectal wall by 
a short, thick pedicle. It occurs in adults and is usually single. 
It is made up of fibrous tissue and is covered with stratified epithe- 
lium when it springs from the anal canal, but has a complete 
mucous membrane over its surface if it originates higher up in the 
rectum. The tumor originates from the submucous connective 
tissue, a thrombosed internal pile, or from the nodules on the free 
edges of the valves of Morgagni, and is at first sessile. 

There may be no symptoms until the growth becomes pedun- 
culated, and then there will be rectal irritation or loss of blood. 
Digital examination will detect the polyp and its situation. If 
the pedicle has been torn by the violent action of the sphincter, 
there may be so much pain that an anesthetic may be necessary 
before a satisfactory diagnosis can be made. 

Myomatous Polyp. — Myomatous polyp, a very rare sort of tumor, 
has the same characteristics as fibrous polyp, except that the tumor 
is made up of muscular tissue in excess of fibrous tissue. 

Villous Tumor. — This rare sort of tumor in the rectum is de- 
scribed by Allingham ("Diseases of the Rectum") as "a lobulated, 
spongy mass, with long, villus-like groups studding its surface." 
Goodsall and Miles had collected thirty-five cases of villous tumors, 



NEW GROWTHS OF THE RECTUM 525 

twelve in their own experience. The tumors appear to originate en- 
tirely from the mucous membrane of the upper rectum in patients 
who are beyond middle life. The growth is at first sessile and as it 
increases in size becomes pedunculated, the pedicle being band-like 
or poorly developed. If it is well developed the tumor has the 
appearance of being slung to the rectal wall as by a mesentery, 
attached obliquely. These tumors do not infiltrate the rectal 
wall, but may be the seat of carcinomatous degeneration. The 
symptoms consist of the escape from the anus of a thin, watery 
fluid. The frequent defecation caused by the tumor is described 
as diarrhea. There may be present dull pains in the region of the 
rectum and hemorrhage, also constipation alternating with diarrhea, 
and cachexia from loss of blood. The growth itself does not appear 
to bleed unless it is prolapsed through the anus. Internal piles 
are apt to complicate the disease. Anesthesia and the rectal specu- 
lum will be necessary in order to map out the situation, size, and 
character of the pedicle of a villous growth. 

Myxomatous Polyp. — Myxomatous polyp is very rare in the 
rectum. A tumor made up of a combination of fibrous tissue and 
mucoid tissue, a fibro myxoma, is occasionally seen. Here, there 
are loose areolar-tissue spaces filled with a thick viscid fluid. The 
diagnosis is made as in the other forms of benign rectal tumors. 
There are no characteristic symptoms beyond an increasing diffi- 
culty in emptying the bowel satisfactorily. 

2. Malignant Tumors 

Malignant tumors of the rectum are cancer and sarcoma, the 
former being frequent, and the latter rare. 

Cancer of the Rectum 

Cancer of the rectum forms about five per cent of cancers of 
all parts of the body (combined statistics of 45,906 cancers by 
Heimann, Zeman, Kronlein, and De Bovis, "Diseases of the 
Rectum," J. P. Tuttle) and about fifty per cent of all cancers of 
the intestine (same statistics). The disease is more frequent in 
men than in women and is found most often between the forty- 
fifth and fifty-fifth years in both sexes, although it may occur at 
any age. The etiology is entirely unknown, except that it is found 



526 DISEASES OF THE RECTUM 

more often in patients who have suffered previously with hemor- 
rhoids, ulceration, or benign tumors of the rectum. 

The most frequent situation of the disease is the upper rectum 
between the sigmoid flexure of the colon and the internal sphincter. 
The lower down in the rectum the disease is situated the greater 
the discomfort to the patient and the greater the likelihood, there- 
fore, of an early diagnosis. 

Cancer of the Anus 

Cancer of the anus is infrequent. It may originate in the skin 
about the anus, in this case being a squamous-celled carcinoma, 
or in the anal canal with downward extension, an adeno-carcinoma. 
Squamous-celled carcinoma is rare and is most often met with in 
women over fifty years of age. An ulcer having an indurated base, 
bleeding easily, and extending into the margin of the anus is the 
appearance generally seen. 

The lymphatic glands in the groin are the ones that are enlarged 
in cases of cancer about the anus. A piece of the ulcer and its base 
should be removed for microscopic examination. 

Pathology and Course. — Pathologically, cancer of the rectum 
belongs to the class of adeno-carcinomata, the disease showing 
an atypical growth of glandular elements. If the connective- 
tissue elements predominate and the stroma is large in amount 
and dense, the tumor is called scirrhus; if, on the contrary, the 
glandular elements predominate and the tumor is soft in consist- 
ency it is called medullary. Colloid degeneration may affect the 
growth; then it is known as colloid cancer. 

In the early stages adeno-carcinoma of the rectum is a sessile, 
rounded tumor, flattened on top, situated in the mucous and sub- 
mucous tissues and freely movable. As the tumor increases in 
size the cancerous outgrowths invade the muscular wall below, 
and the mucous membrane above, so that within a few months 
the tumor is ulcerated on top, fixed in the rectal wall, and of 
irregular outline. This is the condition usually found when cancer 
of the rectum in an early stage is first seen by the physician, 
although the less fully developed growth is occasionally detected 
during a routine examination. 

Involvement of the lymphatic glands in the hollow of the sacrum 
appears to be a relatively early event. 



CANCER OF THE RECTUM 527 

The cancerous ulcer is excavated, with irregular, everted, and 
indurated edges, lying on a base that is of a porky hardness. When 
it has extended nearly round the circumference of the bowel 
stricture occurs, and by this time infiltration of the tissues sur- 
rounding the rectum takes place and the rectum is fixed. The 
ulceration may open into the vagina, bladder, or peritoneum in 
the late stages of the disease, and at this time the abdominal 
lymph glands are affected, and metastatic deposits occur in the 
liver and other organs. 

Symptoms. — Goodsall and Miles have analyzed with great care 
the histories of their cases of cancer of the rectum, with a view to 
detecting any symptoms, however slight, that may excite the 
attention of the physician and suggest a probable diagnosis of this 
dreadful disease. The patient's condition is so uniformly hopeless 
in the later stages that any facts that may lead to early diagnosis 
must be sought with painstaking assiduity. 

In the earliest stages before ulceration has taken place, the patient 
is apt to complain of a well-marked attack of constipation, having 
previously had regular movements without the use of laxatives; 
also there may be slight loss of weight, and after the attack of 
constipation is over there is frequency in the action of the bowels 
excited especially by the ingestion of hot fluids. The bowels at this 
time may act four or five times during the day and not at all at 
night. Goodsall and Miles insist that such a train of symptoms, 
occurring in women who have passed forty years of age, should 
lead to a thorough rectal examination, and I can not but agree 
with them, for any tyro can make a diagnosis in the advanced 
stages when it is too late for treatment to be of avail, and the 
patient's only hope lies in early detection. 

When the ulcerative stage has been reached the symptoms are, 
increased frequency of defecation with difficulty of procuring a 
satisfactory evacuation of the rectum, the appearance of blood and 
mucus in the stools, pain in the rectum from constant straining, 
and progressive loss of weight. 

In the later stages, when the rectum has become fixed, the 
symptoms are, the escape of blood, mucus, and pus without feces, 
deep-seated pain in the pelvis, over the sacrum, and extending 
down the thighs, and general cachexia. 

If there is stricture nearly occluding the lumen of the rectum 



528 DISEASES OF THE RECTUM 

the symptoms are, obstinate constipation alternating with 
diarrhea, intermittent hemorrhage, pain in the rectum and 
also in the abdomen, abdominal distention, emaciation, vomit- 
ing, and obstruction. The odor of cancer in the later stages is 
characteristic. 

Diagnosis. — The diagnosis is founded on the symptoms and on 
the physical examination. The latter shows the anus relaxed, 
patulous, and darker than the surrounding skin, probably caused 
by obstruction to the venous circulation and constant straining. 
The usual situation of the disease has been referred to; the 
anal canal will be found free from disease. With the aid of 
the finger and the proctoscope an accurate conception must 
be obtained of the situation, size, color, consistency, and shape 
of the lesion. 

The growth bleeds easily on the slightest touch, therefore digital 
examination will be followed by hemorrhage. 

Palpation of the glands in the hollow of the sacrum is practiced 
by turning the right forefinger with its palmar surface toward 
the sacrum and feeling on both sides of the rectum for enlarged 
glands in that situation. The inguinal glands should be investi- 
gated also, especially if the disease is situated near the anus, and 
in late stages of the disease secondary deposits in the liver or other 
organs should be sought for. 

Differential Diagnosis. — The following conditions must be ex- 
cluded: — Tuberculous ulceration, extensive inflammatory exudate 
about a blind internal fistula, polypi, villous tumor, simple stricture, 
and gumma. 

Tuberculous ulceration in the rectum is rare. It is attended by 
no distinct tumor, the ulceration does not bleed easily, its base is 
relatively soft, and its edges are not indurated. Tubercles and 
cheesy matter appear in the granulations of the floor of a tubercu- 
lous ulceration and the surrounding induration is less in amount 
than in cancer. The microscope will show the presence of the 
tubercle bacilli. 

Extensive inflammatory exudate about a blind internal fistula will 
present the mucous membrane covering the induration intact, 
except where the fistula opens; the tumor is smooth in outline, 
there is a history .of the discharge of pus, and digital examination 
produces a sudden gush of pus accompanied by a diminution in 



SARCOMA OF THE RECTUM 529 

the size of the swelling. Treatment of the fistula is followed by 
relief of the symptoms. 

Polypi. — Adenomatous or mucous polypi occur almost exclu- 
sively in children under ten years of age. The surface of the growth 
is soft, it is seldom of great size, and is protruded at stool. The 
other sorts of polypi are discrete rounded tumors without indu- 
ration surrounding them. 

Villous tumor has a broad obliquely attached pedicle, it is soft 
and velvety to the feel, and is lobulated. It may cause as many 
as twelve actions of the bowels in twenty-four hours and it rarely 
bleeds unless prolapsed. 

Simple stricture has a firm, even margin. It may be situated at 
the apex of an invagination of the rectum. There is absence of 
irregularity and induration of the tissues surrounding the stricture. 
The bleeding that follows a digital examination is always slight 
in amount and there is a purulent discharge. 

Gumma of the rectum is very rare. There is a history of syphilis. 
The growth is round and smooth and elastic, and the mucous mem- 
brane over it is healthy. A gumma may become softened and 
fluctuate. Iodide of potash given by the mouth will cause a diminu- 
tion in the size of the gumma. 

Sarcoma of the Rectum 

Sarcoma of the rectum is a disease of later life and occurs in 
growths of three pathological varieties: — spinclle-cell, small round- 
cell, and giant-cell, any one of which may take on a melanotic 
change, converting the tumor into a melanotic sarcoma. 

The tumors are single or multiple, they vary in size from half 
an inch in diameter to the size of an orange, and they are situated 
generally in the lowest two inches of the rectum. To the touch 
they are round, of irregular surface, and relatively hard in con- 
sistency, being especially dense in the case of the fibro-sarcomata. 
They appear of the color of the normal mucous membrane, but may 
be of a dark red or grayish color, or, in the melanotic kind, black. 
If there is more than one tumor the different tumors may not be 
alike in color. 

Sarcomas of the rectum grow much more rapidly than do car- 
cinomas, the lymphatic glands being involved relatively early. 

Metastases occur early also. 
34 



530 DISEASES OF THE RECTUM 

The symptoms of sarcoma are not characteristic. The disinte- 
grating tissues have no characteristic odor. The attachment of a 
sarcoma to the wall of the rectum does not spread out like car- 
cinoma, it is abrupt and clearly defined, and only in the late stages 
does it infiltrate the walls extensively. 

Any rapid growing tumor of the rectum should be removed at 
once, and the microscope will make the diagnosis. 



CHAPTER XXVII 

THE DIAGNOSIS OF DISEASES OF THE BREAST 

Anatomy, p. 532. 

Age changes, p. 534 : The infantile breast, p. 534. The breast at puberty, 
p. 535. Lactation hypertrophy, p. 535. The senile breast, p. 536. 

Classification of diseases of the breast, p. 536. 

Anomalies, p. 538 : Complete absence of the breast, p. 538. Incomplete 
development of the breast, p. 538. Supernumerary mammae, p. 538. 

Symptomatic lesions, p. 539., Pain, areas of induration, phantom tumors, 
p. 539. 

Hypertrophies, p. 539: Infantile hypertrophy, p. 539. Galactocele, p. 
539. Diffuse bilateral hypertrophy, p. 540. Senile parenchymatous 
hypertrophy, p. 540. 

Inflammations, p. 542: Mastitis, p. 542; Acute mastitis, p. 542; Mammary 
abscess, p. 542; Submammary abscess, p. 542. Chronic mastitis, p. 543; 
Chronic interstitial mastitis, p. 543; Diffuse mastitis, p. 543; Lobular 
mastitis, p. 542; Tuberculous mastitis, p. 543; Actinomycotic and syphilitic 
mastitis, p. 544. 

Benign tumors, p. 544: Fibro-epithelial tumors, p. 544. Epithelial tumors, 
p. 545. 

Malignant tumors, p. 545: Carcinoma, p. 545; Adenocarcinoma, p. 546; 
Comedo, p. 546; Colloid, p. 546; Cystic, p. 546; Intra-cystic papillomatous 
varieties, p. 546; Medullary carcinoma, p. 546; Scirrhous carcinoma, p. 548; 
Cancer cysts, p. 548; Paget 's disease of the nipple, p. 548, Sarcoma, p. 549. 

Diagnosis of tumors of the breast in general, p. 549: History, p. 550. 
Age, p. 550. Duration of the tumor, p. 551. Situation of the tumor, p. 551. 
Mobility of the tumor, p. 552. Inspection and palpation, p. 552. Dimpling 
of the skin, p. 552. Retraction of the nipple, p. 553. Enlarged glands in 
the axilla, p. 553. Late signs of cancer, p. 553; Discharge from the nipple, 
p. 553; Ulceration of the skin, p. 553; Skin metastases, p. 553; Metastases 
in other organs, p. 553; Enlarged supraclavicular glands, p. 554; Cachexia, 
p. 554; Inadvisability of making exploratory incisions, p. 554. 

Although diseases of the breast are commonly regarded as in the 
province of the surgeon, the breasts arc distinctly a part of woman's 
reproductive apparatus and in intimate relationship through 
the nervous system with the uterus, as attested by the uterine 
contractions induced by suckling, by the development of the 
breasts and their functions coincident with the growth of the 
uterine organs, even under abnormal conditions, by the sexual 

531 



532 DISEASES OF THE BREAST 

feelings caused by manipulation of the breasts, and finally, by 
the swelling and pain in the breasts associated with menstruation 
in the case of uterine disease; therefore we shall discuss here the 
diagnosis of the diseases of the mammae. 



ANATOMY 

The breasts consist of racemose glandular structures situated 
beneath the skin one on each side of the sternum. Each gland 
appears as a hemisphere projecting from the front of the thorax 
under the skin and covering a portion of the pectoralis major and 
a smaller portion of the serratus magnus muscles. The breast 
extends from the level of the second rib above to the level of the 
sixth rib below, and laterally from the margin of the sternum to 
the axillary line. The various lobes and lobules of which the gland 
is composed radiate from the nipple and extend to unequal dis- 
tances in different parts of the breast, sometimes forming a pro- 
longation of the gland tissue into the axilla, over the serratus 
magnus muscle, or toward the sternum. In the rare event of the 
occurrence of supernumerary mammae the glands are found on a 
line drawn from the anterior margin of the axilla downward through 
the nipple over the flank, the so-called "milk liner (See Fig. 
200.) 

The nipple, cylindrical in shape and about half an inch in 
diameter, projects about half an inch from a point a little below 
and to the median side of the summit of the hemisphere. Its 
top is made rough by fissures and in the center is a depression 
in which are the openings of the milk ducts. 

Surrounding the nipple is the areola, a circle of pigmented, 
wrinkled skin, in which are sweat glands and from a dozen to twenty 
little elevations formed by the sebaceous glands. 

The mammary gland rests loosely upon the pectoral fascia, so 
loosely that the entire breast is freely movable. A sagittal section 
of the mamma shows it to be made up of gland tissue, all the 
ducts of which converge at the nipple ; of fat, fibrous tissue, and 
skin. The gland tissue is firm in texture and of a pale reddish 
color. There are from fifteen to twenty excretory ducts, each one 
coming from a lobe, every duct having a spindle-shaped dilatation 



ANATOMY 



533 



as a reservoir for milk just before it emerges from the apex of the 
lobe into the nipple. 

The lymphatic glands of the axilla receive the greater number 
of the lymphatic vessels of the breast and are disposed in three 
groups : the pectoral, at the outer margin of the pectoralis muscle ; 



CLAVICLE- 



VECTOR A LIS MAJOR 



FIBROUS SEPTUM 
GLAND SUBSTANCE-/ 



ADIPOSE TISSUE 



AREOLA 
NIPPLE 



-THIRD RIB 



-AREOLAR TISSUE 




FIRST 
RIB 



SECOND 
RIB 
PECTORALIS 

MINOR 
INTERCOSTALES 
SHEATH OF PEC- 
TORALIS MAJOR 



.SUPERFICIAL 
FASCIA 



-FOURTH RIB 



-LUNG 

ADIPOSE TISSUE 
HORIZONTAL PLANE 
OF NIPPLE 



-FIFTH RIB 



SIXTH RIB 



Fig. 197. — Vertical Section of Right Breast, Inner Surface of Outer Segment. 

(Testut.) 



the axillary proper, in the loose adipose tissue of the axilla; and 
the subscapular, between the scapula and the posterior wall of the 
thorax. The anastomosis of the lymphatics of the breast is ex- 
ceedingly free and it is easy to see how the skin may become in- 
volved early in cancer of the breast. The pectoral group of axillary 
lymphatic glands is the one usually first infected in this disease. 



534 DISEASES OF THE BREAST 



AGE CHANGES 

The Infantile Breast. — The breast at birth consists of a nipple 
covered with epidermis, which differs from normal skin. The 
mamma is surrounded by a non-pigmented areola. On section 
the breast is seen to be made up of branching ducts surrounded 
by loose areolar tissue and fat. 

Longridge, who studied the mammary glands of still-born 




Fig. 198.— Dissection of the Lower Half of the Breast, Showing the Anatomical 
Arrangement of the Milk Ducts. (Jewett.) 

infants, found that in large children with abundance of subcuta- 
neous fat the breasts are usually well developed, irrespective of sex. 
The breast tissue can be felt distinctly as a solid mass lying below 
the primary areola, and on squeezing it a fluid, which on microscopic 
examination is indistinguishable from milk, can be expressed. 
Whatever the cause of the activity of growth in the breast of the 
new-born infant may be, and many theories have been advanced, 
such as the existence of a "chemical messenger" in the circulation, 



AGE CHANGES 



535 



or an internal secretion from the maternal placenta, . the growth 
and the secretion cease soon after birth and the breast is quiescent 
until puberty approaches. 

The Breast at Puberty. — At puberty the whole breast enlarges, 
the nipple becomes larger also, and is more sensitive; the areola 
increases in size and becomes pigmented to a moderate degree in 
brunettes. Acini lined with epithelium are formed by bulbous 
outgrowths from the ducts, and there is an increase both in the 
gland structures and the intralobar stroma. 

Lactation Hypertrophy. — The breasts become fuller, the veins are 



1ST 



^'C 



i 



u 



<s& 




Fig. 199.— Lymphatics of the Left Breast. (Sappey.) 



prominent, and the patient has a sensation of swelling of the breasts 
during the; second month of pregnancy and later. The nipples 
become prominent and the areola pigmented. In the wrinkled skin 
of the latter, the enlarged sebaceous glands, twelve to twenty in 
number, stand up as little elevations. During the fifth month 
there appears a secondary areola outside the primary areola, 
consisting of a network of pigmenl around light spots, each repre- 



536 DISEASES OF THE BREAST 

senting a circle round the opening of a sebaceous gland. Colostrum 
may be pressed from the nipple by skillful stroking of the breast 
toward the areola after the third month of pregnancy. The 
secretion of milk is not established until the end of the second day 
of the puerperium. On section of a breast during lactation one 
notes that the gland structure is enormously hypertrophied, the 
intralobular connective-tissue stroma having, to all intents and 
purposes, disappeared, and the blood-vessels and lymphatics are 
much enlarged. 

The Senile Breast. — Atrophy takes place early — between thirty 
and forty — in the case of women whose breasts have not undergone 
lactation hypertrophy. In the latter event the atrophy begins 
with the onset of the menopause. The gland structure shrinks, 
but, if the woman is well nourished, fat takes its place and the 
breast may retain its former size. When senile atrophy is well 
advanced the breast consists of bands of fibrous tissue, with oc- 
casional remains of a duct or an acinus lined with atrophic epithe- 
lial cells surrounded by fat and radiating from the nipple. 



CLASSIFICATION OF DISEASES OF THE BREAST 

The following classification is taken from J. C. Bloodgood's 
excellent article on diseases of the female breast in Kelly and 
Noble's " Gynecology and Abdominal Surgery/' being based on a 
clinical and pathological study of 1,048 lesions of the breast, 
observed in the surgical pathological laboratory of the Johns 
Hopkins Hospital. 

I. Anomalies. 
II. Symptomatic Lesions. 

1. Pain (neuralgia of breast, mastodynia). 

2. Areas of congestion (phantom tumors). 
III. Hypertrophies. 

1. Infantile (duct ectasia). 

2. Puberty hypertrophy (normal). 

3. Lactation hypertrophy (physiological). 

4. Diffuse bilateral hypertrophy (pathological). 

5. Senile parenchymatous hypertrophy, with and without 

cvst formation. 



CLASSIFICATION 537 

IV. Inflammations (Mastitides). 

1. Pyogenic, with abscess formation. 

(a) Associated with lactation. 

(b) Not associated with lactation. 

2. Chronic interstitial, with parenchymatous atrophy and 

without cyst or abscess formation. 

3. Tuberculosis. 

4. Actinomycosis. 

5. Syphilis. 

V. Benign Tumors. 

1. Fibro-epithelial tumors: 

(a) Intracanalicular myxoma (periductal myxoma or 

fibroma- Warren) . 
(6) Adenofibroma. 

2. Epithelial tumors: 

(a) Adenoma (cystadenoma). 

(6) Cysts with intracystic papilloma. 

(c) Simple cyst, single or multiple (see senile parenchy- 

matous hypertrophy). 

(d) Galactocele (see lactation hypertrophy). 

3. Miscellaneous rare tumors: — lipoma, enchondroma, lymph- 

angioma, dermoid cysts, calcium deposits, encysted 
foreign bodies. 

VI. Malignant Tumors. 

1. Carcinoma. 

(a) Adenoca cinoma. 

(b) Medullary carcinoma. 

(c) Scirrhus carcinoma. 

(d) Cancer cysts. 

2. Sarcoma. 

(a) Secondary to intracanalicular myxoma. 

(b) Non-indigenous. 

Let us now consider briefly the different le ions of the breast 
that figure in the preceding classification before proceeding to 
a clinical diagnosis of tumors of the breast in general {w 
page 549). 



538 



DISEASES OF THE BREAST 



I. ANOMALIES 

Complete absence of the breast, usually affecting one breast only, 
has been described as a very rare anomaly and is due to lack of 
development in early embryonic life. Sometimes the ovary on 
the corresponding side is absent also. 

Incomplete development of the breast, with or without absence 
of the nipple, is much more common than absence and is apt to be 
associated with anomalies of the uterine organs. When the nipple 
is wanting the areola is often imperfectly formed or absent al- 
together. 

Supernumerary mammae are not very rare. They are usually near 




Fig. 200. — The "Milk Line" or Situation of Supernumerary Mammae, also the 
Breast Divided into Quadrants. (Warren.) 



the situation of the normal breast or in the "milk line/' (see page 
532). Garre observed five developed mammae, two on the thorax, 
one in each axilla, and one in the median line below the ensiform 
cartilage. Some authorities consider that seven pairs of mammae 
existed originally in the human race, situated in the "milk line," 
three above and three below the present normal pair, and that 
supernumerary breasts indicate a return to a primal type. 

A remarkable case has been reported by Blum (Miinchen. med. 
Wochenschr., May 21, 1907) of a girl seventeen years old who had 



HYPERTROPHIES 539 

two well-developed mammae in the normal situation and a third 
mamma in the region of the mons veneris the size of a goose egg and 
surmounted by seven nipples. The two normal mammae had no 
secretion, but four of the seven nipples of the supernumerary 
breast secreted a copious amount of colostrum regularly just before 
and during the first day of each menstruation. 



II. SYMPTOMATIC LESIONS 

Pain in the breast associated with a localized swelling is not 
uncommon, especially in young childless married women at the 
time of menstruation. The painful swelling is firm, but disappears 
when menstruation is over. Sometimes gynecologists see areas of 
induration in the breasts of patients with uterine disease. In a 
doubtful case of a tumor which has existed for a long time the 
patient should be anesthetized and careful palpation will show 
whether the tumor is a phantom tumor or not. If a breast tumor is 
found to be real, the wisest course is to remove it at the same sitting, 
having, of course, already gained the patient's consent, and have 
the tumor examined by the pathologist. Mammary neuralgia 
may be due to pressure on the breasts from badly fitting corsets, 
or from traction in the case of excessively pendent breasts, and is 
commonly observed in neurotic women at the time of menstruation. 
It occurs also in anemic women and in sexually precocious girls. 
Only when the pain is present in one breast alone does the symptom 
call for careful investigation of the breasts. 



III. HYPERTROPHIES 

Infantile hypertrophy is a rare affection due to the abnormal 
distention of the ducts with desquamated, degenerated epithelium. 
The breast at this time is more apt to become infected and mas- 
titis ensues often. Ordinarily the swelling of the breast subsides 
spontaneously. 

Puberty and lactation hypertrophy have been considered on page 
535. 

Galactocele is a cystic tumor occurring during lactation and 
caused by the dilatation of a duct. The tumor is flask-shaped; 



540 DISEASES OF THE BREAST 

with the mouth of the flask at the nipple. Fluctuation is present 
and the skin and nipple are normal. In some cases there are 
several of these tumors in a breast. Absence of inflammatory 
thickening should distinguish a galactocele from a pyogenic mas- 
titis. 

Diffuse Bilateral Hypertrophy. — Excessive enlargement of the 
breasts due to abnormal growth of breast tissue, a sort of adeno- 
fibroma, found mostly in young unmarried women, is always a 
bilateral disease. The increase in size is slow, requiring from one 
to fourteen years to attain a considerable development, and the 
enlargement is first noticed between eleven and thirty years of age. 
Occasionally the progress of these cases is rapid, as in the one re- 
ported by Durston, where the two breasts weighed, after removal, 
sixty-four and forty pounds, respectively, the growth having taken 
place within four months. This, I think, is the largest case on 
record. 

The enlargement begins in one breast and after a time the op- 
posite breast also begins to grow. The breasts are at first full and 
firm, but later become flaccid. The areolae are increased in diameter 
and the nipples become flattened by pressure. The great bulk 
of the breasts, which may reach nearly to the knees, may impede 
locomotion or even interfere with respiration. No cases of cancer 
occurring in diffuse bilateral hypertrophy have been recorded. 

Senile Parenchymatous Hypertrophy. — This disease, forming a * 
quarter of all the benign lesions and occurring during the cancer 
age, is the most important of the non-malignant tumors. 

The etiology is not known. The pathology consists of an increase 
in the parenchyma, the epithelial cells proliferating and degenerat- 
ing, associated with dilatation of the ducts and acini, — an adeno- 
matous type. In the early stage there are no symptoms, unless, 
possibly, pain and tenderness associated with areas of increased 
density in the breast. With further distention of the ducts cysts 
are formed, the lining epithelium being destroyed in the course of 
time, or the dilated ducts, instead of being filled with fluid, contain 
proliferating epithelial cells, — the adenocystic type. 

If one tumor is present it may feel like an area of induration 
without definite boundaries, or it may be a sharply circumscribed 
growth, in the latter event being at times large enough to involve 
an entire quarter of the breast. 



HYPERTROPHIES 541 

Palpation will show a cystic character (the cyst being generally 
spherical) or perhaps a simple hard area. The nipple and the skin 
over the tumor are normal. If a quadrant of the breast is involved 
the normal contour will be altered. The adenocystic type of tumor 
grows rapidly, the tumor reaching a considerable size in a few days, 
but cases are on record where the growth had existed for several 







1 






V 


i r 






; % : 







Fig. 201. — Diffuse Bilateral Hypertrophy of the Breasts. (Warren-Gould.) 

years. There may be a discharge from the nipple, and pain is a 
symptom of the early stages. 

If there are two or more tumors present in one or both breasts, 
the diagnosis is made by finding one circumscribed cystic tumor 
and several smaller shot-like tumors, generally in the opposite 
breast. 

On exploratory section a cyst has thin walls with smooth inner 



542 DISEASES OF THE BREAST 



surface and the contents are clear and fluid, never bloody, or thick 
as in the case of a cancer cyst. 



IV. INFLAMMATIONS— MASTITIS 

Mastitis may be due to the Staphylococcus albus or aureus, 
to the tubercle bacillus, to the Spirochseta pallida of syphilis, 
and very rarely to the actinomyces bacillus. It is (a) acute, or 
(b) chronic. 

a. Acute mastitis occurs almost without exception during 
lactation and generally before the fourth month of lactation. It is 
more often met with in primiparae. It is probable that infection 
reaches the gland tissue through the nipple and the ducts in most 
cases, but may get there by way of the blood or from neighboring 
anatomical structures. 

The early caking of the breast during the first few days of labor 
seldom leads to abscess formation. At any time after this, gen- 
erally in the first four weeks, always before the fourth month of 
lactation, one or more areas of induration may be observed in one 
breast, attended by a rise of body temperature, a chill, and pain 
and tenderness in the breast. A crack in the nipple is often to be 
found in such a case. Resolution may take place without abscess 
formation if the breast is properly supported and passive hyperemia 
induced after Bier's method. If not, a mammary abscess results; 
the indurated area becomes reddened, the pain increases so that 
nursing is impossible, there are leucocytosis and a constant elevation 
of temperature, and fluctuation with adhesion of the skin to the 
indurated mass can be made out. 

Abscesses are apt to be multiple and the breast may be riddled 
with them. Sometimes not only the parenchyma of the gland is 
infected, but the loose connective tissue between the breast and 
the pectoral muscle is involved and a submammary abscess is the 
result. 

The important point in diagnosis is to recognize the beginning 
of pus formation, so that an early incision may be made and thus 
obviate destruction of breast tissue, sinuses, and a prolonged sup- 
puration with its deleterious effects on the system. Therefore the 
appearance of redness of the skin over an indurated area of gland 



INFLAMMATIONS 543 

tissue, a union of the skin with the tissues underneath, continued 
elevation of temperature and leucocytosis, are indications that 
pus has formed, even though fluctuation can not be determined. 

A rare form of "acute carcinoma'' or " carcinomatous mastitis" 
developing rapidly in the course of mastitis has been described 
by Volkmann. 

b. Chronic mastitis includes both suppurative and non-sup- 
purative inflammations of the breast. The pyogenic variety may 
follow an acute mastitis, in which case the abscess wall, lined with 
granulation tissue, becomes thickened and the pus filling the 
abscess is of thin consistency. 

Chronic interstitial mastitis is a chronic inflammation of the 
interstitial connective tissue of the gland. The connective tissue 
is increased in amount and crowds out the acini and ducts. In 
the later stages there is atrophy of all the structures and the 
breast on section shows a dull opaque white surface, with very few 
of the pink spots of secreting gland substance to be seen. Th*e 
disease may be limited to individual lobules of the mamma, in 
this case being referred to as a lobular mastitis, or it may involve 
the entire gland — diffuse mastitis. 

Chronic interstitial mastitis is found in women of middle age 
in the non-lactating breast, it has no distinctive symptoms, and 
must be differentiated from cancer. 

Chronic mastitis generally affords a history of an acute attack 
of mastitis some time in the past, the lump in the breast has been 
stationary in size since it was first noticed, it is painful, and more 
tender than cancer, it does not involve the surrounding structures, 
either muscle below, or fat and skin over it, and the tumor is freely 
movable. 

Tuberculous mastitis, forming six per cent of all benign lesions 
of the breast, is a form of chronic mastitis occurring between the 
ages of twenty-five and thirty-five, and occurring more often in the 
non-lactating than in the lactating breast. As a rule, it occurs 
after the fourth month of lactation and is unilateral. 

There may be no family history of tuberculosis and there may be 
no other lesions of tuberculosis elsewhere in the body. The disease 
begins in an area of induration, generally in the region of the 
areola. The induration breaks down and an abscess is formed 
without acute symptoms of pain and fever, the abscess ruptures 



544 DISEASES OF THE BREAST 

spontaneously, leaving a sinus. At this time an exact diagnosis 
may be made by means of the microscopic examination of tissue 
removed from the abscess or sinus wall. 

Actinomycotic and Syphilitic Mastitis. — These forms of mastitis, 
extremely rare, are diagnosed in the case of actinomycosis by the 
characteristic appearance of the tissues (see page 332). In the 
case of syphilis a primary lesion has been known to occur on the 
nipple. It has the characteristic appearance of chancre elsewhere 
(see page 406). Mucous patches have been observed both on the 
nipple and in the folds under a pendulous breast. Only a few cases 
of gumma of the breast, and diffuse syphilitic mastitis have been 
described. The diagnosis of syphilis rests on the history with the 
definite period of incubation of the disease, and on the appearance 
of the lesions, which are the same as in the vulva (see page 406). 

Search should be made for the spirochseta pallida in excised 
tissue or the discharges. 

It is thought that the tissue changes resulting from lactation 
mastitis furnish a predisposition to cancer and John Speese (An- 
nals of Surgery, Vol. LL, Feb. 1910, p. 212) advises removal of 
all indurated areas from this cause occurring in the breasts of 
women who are near the menopause. 



V. BENIGN TUMORS 

1. FlBRO-EPITHELIAL TUMORS 

These are intracanalicular myxomata and adenofibromata, the 
former being the more common, and both together forming 39 
per cent of 333 benign tumors of the breast observed by Bloodgood. 
The tumors are single, or multiple (in about one-fifth of the cases), 
they occur in one or both breasts and in young women, the average 
age at which they are first noticed being less than twenty-five 
years. 

Cancer has never been observed as a complication of this sort 
of tumor. The growth is slow. Most of the tumors are single and 
small and may be removed without sacrificing the breast. 

Recurrence of a tumor of the fibro-epithelial type should be 
regarded as an instance of successive tumors developing at different 
periods of time from separate foci, rather than the growth of a new 



MALIGNANT TUMORS 545 

tumor from elements of the first one, and as these tumors are 
multiple in a fifth of all cases, such a so-called " recurrence" might 
well be more common than it is. As a matter of fact these "re- 
currences" are very rare. 

Large intracanalicular myxomata sometimes occur in older 
women — from thirty to fifty years of age. These have a tendency 
to develop into sarcoma and therefore call for a radical operation. 

The adenofibroma is always relatively small in size, is spherical, 
hard and firm, even calcareous in some instances; the older the 
tumor the more fibrous tissue is present. 

2. Epithelial Tumors 

Cystic Adenoma. — This is a rare form of growth consisting of a 
small, encapsulated, freely movable tumor occurring in breasts of 
sterile women between the ages of thirty and fifty years. 

Cysts with intracystic papilloma are also rare and constitute a 
form that can not be distinguished clinically from malignant cysts 
of the same characteristics. The chief symptom of the benign 
cyst is a discharge of blood from the nipple. The cyst is generally 
single, occurs in women between the ages of thirty and sixty, 
and its growth is generally slow. On account of the impossibility 
of making an exact diagnosis, such a cyst should be removed 
together with the entire breast and the pectoral muscle and axillary 
glands. 

For a discussion of simple cysts and galactocele see page 539. 



VI. MALIGNANT TUMORS 

Carcinoma 

The average duration of life in cancer of the breast from the 
first time the tumor is noticed until death is 3.77 years. In the 
case of atrophic scirrhus a patient has been known to live over 
nine years, but only in this form of cancer has life been prolonged 
so far. The disease is, then, of comparatively slow growth — nearly 
four years on the average — and the opportunities for early diag- 
nosis and removal of the disease are therefore ample. 

Cancer of the breast may be divided, for the purposes of diag- 

35 



546 DISEASES OF THE BREAST 

nosis, into the following varieties: — adenocarcinoma, medullary 
carcinoma, scirrhus, and cancer cysts. 

Adenocarcinoma. — Adenocarcinoma formed 14.4 per cent of the 
carcinoma cases seen in Halsted's clinic. In this species of cancer 
the inoperable cases were the fewest and the percentage of cures 
greatest; in other words, the disease progresses more slowly and 
involves the surrounding structures later than in the other forms 
of cancer. Bloodgood enumerates four varieties of adenocarcinoma, 
namely: the comedo, or duct cancer; the colloid; the adenocystic ; 
and the malignant intracystic papilloma. Each may be pure, or 
any one may be combined with medullary or scirrhous cancer. 

Comedo Adenocarcinoma. — This is the commonest type. The 
cut surface of a breast affected with this disease shows trabecular 
of fibrous tissue in the meshes of which are round, granular areas 
from the center of which worm-like comedo bodies can be ex- 
pressed, the appearance being characteristic. The tumor has no 
capsule. The disease begins as a small circumscribed tumor and 
may be shot-like, sometimes being multiple, and rarely occurring 
in both breasts. 

Colloid Adenocarcinoma. — This differs from the preceding in 
having a thin capsule, and presenting on section — bulging between 
the fibrous trabecular — pink gelatinous lobules which are pathog- 
nomonic. 

Cystic Adenocarcinoma. — This may be either circumscribed or 
diffuse, the latter occurring generally during senile parenchy- 
matous hypertrophy. The disease is characterized by the occurrence 
of cysts in an encapsulated tumor showing on section the char- 
acteristics of adenoma. Glandular involvement is late and a 
permanent cure following operation may be expected, even if the 
skin and muscles are involved. 

Adenocarcinoma with Papilloma in the Cysts. — This is similar 
to the benign form (cystic adenoma, see page 545) except that the 
papilloma proliferates and becomes an infiltrating fungous growth 
resembling medullary carcinoma. 

A discharge of blood takes place from the nipple just as in the 
benign form, the only difference being that the malignant type 
infiltrates and the fungous growth is different in appearance from 
the benign papilloma. 

Medullary Carcinoma.— This formed three per cent of Halsted's 



MALIGNANT TUMORS 



547 



cases of cancer. It grows rapidly, but does not infiltrate as soon 
as scirrhus. It is the form of cancer most often found in the lac- 
tating breast. Beginning as a small, circumscribed, soft tumor, 
it soon becomes larger and begins to ulcerate. On section the 
fibrous stroma may be seen enclosing much granular, friable tissue, 
which may be forced out on pressure. 
This form of cancer is frequently associated with adenocarcinoma 




Fig. 202. — Scirrhous Cancer of the Left Breast. (Warren-Gould.) 

both of the comedo and the cystic varieties. There is one type of 
medullary carcinoma, called the hemorrhagic, which is characterized 
by the occurrence of patches of old and fresh blood throughout 
the tumor, as seen when a section is made. 

Medullary carcinoma often resembles sarcoma and pathologists 
are puzzled to differentiate them. 



548 DISEASES OF THE BREAST 

Scirrhous Carcinoma. — Scirrhous cancer may be divided into the 
circumscribed, the small infiltrating, and the large infiltrating scir- 
rhus. On cutting a scirrhous tumor of whatever sort, the physician 
experiences a gritty sensation as the knife goes through the tough 
tissue and on feeling the cut surface with the finger it is lumpy and 
hard. To the eye it shows much white fibrous stroma with yellow 
dots and lines in the interstices. The disease infiltrates the surround- 
ing structures relatively early and has all the marks of malignancy 
within twelve months of the first appearance of the tumor. Glan- 
dular involvement and metastases to other organs are common. 

The large infiltrating scirrhous cancers are the most dangerous 
and furnish the largest proportion of the inoperable cases. Ac- 
cording to Bloodgood's analysis of the cases in Halsted's clinic, 
70 per cent of all the cancers were scirrhous, and of these 10 per 
cent were circumscribed, 29 per cent were large infiltrating, and 
31 per cent were small infiltrating scirrhus. 

The diagnosis rests on the presence of a hard tumor presenting 
all the characteristics of malignancy (see page 552). 

Cancer Cysts. — These tumors are rare, forming only 2.7 per cent 
of all tumors of the breast. The diagnosis from benign cyst, before 
operation, is impossible. 

On exploratory incision the cancer cyst contains blood, but no 
papilloma, or it contains a thick, grumous material formed from 
broken-down epithelial cells. A galactocele, on the other hand, 
has thin, smooth walls and is surrounded by lactating breast tissue ; 
a circumscribed, chronic abscess has a thick wall and thin, clear 
or cloudy, serous contents; a papillomatous cyst generally con- 
tains blood and papillomatous material; and a malignant adeno- 
matous cyst has an infiltrating fungous growth lying in bloody 
contents. True cancer cysts are extremely malignant and are 
generally fatal, whether operated upon or not. 

Paget's Disease of the Nipple. — Chronic eczema of the nipple 
associated with ulceration of the nipple, occurrng in women between 
forty and sixty, is now regarded as a secondary manifestation of 
cancer of the breast, the 'primary lesion being a malignant tumor 
of the breast, the nipple being involved by metastases along the 
ducts or lymphatics. Paget described the disease in 1874 and until 
very recently the lesions of the nipple and areola were thought to 
precede the formation of a tumor in the breast. 



DIAGNOSIS OF TUMORS IN GENERAL 549 



Sarcoma 

True sarcoma of the breast is rare. Bloodgood found eighteen 
among five hundred and five malignant tumors. It occurs as pri- 
mary sarcoma of the stroma of the breast, as sarcoma arising in 
intracanalicular myxoma, and as metastatic sarcoma from some 
other organ. The primary sarcoma presents on section soft, 
friable tissue lining the walls of cyst cavities; the intracanalicular 
myxomatous form has distinct lobulations and the characteristics 
of myxoma. 

Sarcoma shows the manifestations of malignancy, the patients 
are between the ages of forty and fifty, and the growth of the tumor 
is rapid. 

THE DIAGNOSIS OF TUMORS OF THE BREAST IN GENERAL 

The importance of early diagnosis in diseases of the breast can not 
be insisted on too often. The operating surgeons constantly see 
cases where the probable diagnosis was not made until too late 
and as, at the present time, the only hope for the patient with 
cancer lies in its early removal, delay on the part of the general 
practitioner, who sees nearly all of the patients, seals the death 
warrant. In this connection M. H. Richardson says: — "The evils 
of wrong diagnosis need not be exemplified, but the evils of a too- 
positive opinion do need emphasis, especially those opinions which, 
if wrong, sacrifice health, or even life itself." 

W. L. Rodman, from a large operative experience, estimates 
that it is impossible to make a diagnosis of cancer in an operable 
stage in about ten per cent only of all cases. 

In other words, an early diagnosis of cancer can be made in 
ninety per cent of all cases of cancer. That such a percentage 
does not obtain at present we have only to glance at the oper- 
ability record of a large clinic, such as Halsted's at the Johns 
Hopkins Hospital. Of 464 patients admitted with the diagnosis 
of primary carcinoma of the breast, in only 349, or 75.3 per cent, 
was the disease in an early enough stage of development to permit 
of a radical operation at tin* hands of zealous advocates of this sort 
of operating. In all probability the percentage would be much 



550 DISEASES OF THE BREAST 

lower amcng less enthusiastic hospital surgeons, and even less 
among general practitioners. 

According to W. L. Rodman the three most important points 
to consider in the diagnosis of a tumor of the breast are, the age of 
the patient, the situation of the growth, and whether or not it is 
adherent to the surrounding tissues. 

History. — The history that malignant tumors have occurred in 
the family of the patient may occasionally be obtained, but in at 
least three-quarters of the cases the family history is negative in 
this respect. This is the case also in tuberculosis of the breast, 
forming about six per cent of the benign lesions of the breast and 
occurring between the ages of twenty-five and thirty-five. 

The history of syphilis in the patient may point toward the 
very rare lesion, gumma of the breast, and the fact that the patient 
has been exposed to the contagion of syphilis might lead to the 
detection of chancre of the nipple, an unusual disease. 

Injuries or blows on the breast were formerly thought to be 
causative of tumors. Now we may say that nothing is known of 
the etiology of tumors except that the inflammatory lesions follow 
infection, which may sometimes be traced by the history. 

Married women are more subject to breast cancer than the un- 
married, and the fruitful more than the sterile. 

The date when the tumor was first noticed must be carefully 
recorded, also whether it has grown larger, and the amount of pain 
or tenderness, both in the early stages of the tumor and during the 
time intervening between its beginning and the present consultation. 

Age. — The only disease of the breast occurring in infancy is ab- 
normal distention of the ducts (duct ectasia) with a discharge from 
the nipple, sometimes associated with pyogenic mastitis, therefore 
the breast is practically immune from disease until the hyper- 
trophy of puberty. At this time and after, the fibro-epithelial 
tumors (adenofibroma and intracanalicular myxoma) may occur. 
During lactation an induration is generally due to pyogenic mastitis. 
Any of the inflammations may occur from puberty to the meno- 
pause, also any of the benign tumors. 

Carcinoma is essentially a disease of the atrophic breast, but it 
may occur as early as nineteen (case of A. J. McCosh). Only a 
few cases, however, have been reported of the disease occurring 
earlier than twenty-five. 



DIAGNOSIS OF TUMORS IN GENERAL 551 

Rodman analyzed 5,000 cases of cancer of the breast, with refer- 
ence to the age at which it was diagnosed, and found that a fifth 
of all the cases occurred in women under 40 years of age. Almost 
an equal number occurred in the two decades between 40 and 50, 
and between 50 and 60. After 60, cancer of the breast is infrequent. 
Therefore the age of greatest frequency is the time of the menopause 
and the succeeding years while the breast is undergoing atrophic 
changes. 

Sarcoma, forming about three and a half per cent of all malignant 
tumors of the breast, is found in women who are in the neighbor- 
hood of 40 years of age. Bloodgood puts the age at 40 to 50, 
but says that sarcoma occurs as a complication in intracanalicular 
myxoma, which commonly is found in younger women. This may 
account for Gross' earlier statistics. In 35 of his cases of "cystic 
sarcoma" the average age was 33.7 years, and in 60 cases of "solid 
sarcoma," only 13 were in women over 40 years of age. 

Even at the present time the differentiation of sarcoma from 
medullary carcinoma is often a difficult problem for the patholo- 
gist, and a second examination of the specimen not infrequently 
brings a change in the diagnosis. 

To summarize, if the patient is under twenty-five the presump- 
tion is that a given tumor of the breast is benign; if over twenty- 
five it is either benign or malignant, with the probability of the 
latter increasing as the age of the patient becomes more advanced. 

Duration of the Tumor. — A tumor which has been present a year 
or more and yet manifests no evidences of malignancy (see page 546) 
is generally benign; still, a scirrhous cancer may exist for as long 
as five years without involving the surrounding tissues to an ap- 
preciable extent. 

Situation of the Tumor. — Cancer is more frequently found in the 
upper and axillary side of the breast, although it may be found in 
any portion; next in point of frequency is the region of the areola. 
Malignant tumors in this situation are apt to pull on the nipple 
and cause retraction more often than in the case of growths situated 
in the outer portions of the gland. 

Benign tumors are more frequently found in the sternal half of 
the breast, and are very rare in the areola. Mastitis, with the 
exception of the tuberculous form, occurs chiefly in the outer, 
axillary side. 



552 DISEASES OF THE BREAST 

Cancer generally involves one breast only, but has been found 
in both breasts in about five per cent of all malignant tumors. If 
a benign tumor has been removed from one breast, another tumor 
occurring in the opposite breast would probably be benign also. 
As a rule, multiple tumors are benign. 

Mobility of the Tumor. — Inspection and Palpation. — If a tumor 
is freely movable and not adherent to the skin it is not cancerous. 
If, on the other hand, it is fixed either to the muscle below or, more 
important, to the skin, causing dimpling, — and when situated in 
the region of the areola, retraction of the nipple, — the growth is 
almost certainly cancer. To determine the connection of the 
tumor with the skin, expose both breasts fully, place the palm of 
each hand flat on the center of each breast, and move the breasts 
alike to and fro in every direction until asymmetry is produced in 
the diseased one by the adhesion of the tumor to the skin. This 
procedure is especially valuable in deep-seated growths in large 
and fatty breasts. 

In palpating the breast a malignant growth, if it has reached the 
surface, is hard and of irregular outline; if situated deeply its 
connection with surrounding tissues limiting its mobility or causing 
asymmetry must be the determining diagnostic features. 

If the nipple is retracted it should be seized firmly and pulled out, 
comparing it with the nipple of the opposite breast. The physician 
should bear in mind that many women have ill-formed and re- 
tracted nipples from birth. Should both nipples show deformity 
the patient should be questioned as to their usual shape. 

Atrophy of the subcutaneous fat, even if the tumor is not actually 
connected with the skin, is a strong indication of cancer. 

To determine any union between the tumor and the subcutaneous 
areolar tissue or the reticular layer of the corium some surgeons 
pick up the skin over the tumor and thus demonstrate a shortening 
of the fibrous trabecule of the subcutaneous tissue or corium, 
comparing this finding with the condition of the skin elsewhere in 
the breast; others use the test of moving both breasts about as just 
described. Another method is to grasp one breast with both hands, 
whereupon the skin intervening between the hands will show 
dimpling if cancer is present and a smooth bulging surface if a 
benign tumor is present. 

In practising inspection and palpation the physician makes a 



DIAGNOSIS OF TUMORS IN GENERAL 553 

mistake if, to save the patient's feelings, he does not expose 
thoroughy both breasts, the chest being in a good light. The 
slightest amount of asymmetry should lead to a thorough investi- 
gation as described above. 

Retraction of the nipple, as has been pointed out, is a sign of 
cancer in the early stages of malignant disease situated in the 
neighborhood of the areola. 

Enlarged glands in the axilla, formerly thought to be an important 
diagnostic sign of cancer, are now found to be fairly constant 
signs of benign tumors and inflammations of the breast. 

Pain in the breast is a common symptom of the last two lesions 
also, and appears in cancer only in the inoperable, late stages. 
Pain, unassociated with tumor, occurs also in neuralgia of the 
breast (mastodynia), a rare condition except where associated 
with menstruation or the menopause. In the latter event, it may 
be due to senile parenchymatous hypertrophy. Pain in the region 
of the breast may be due to rheumatism of the pectoral muscle. 
In this case it should be called forth by abducting the arms on the 
chest. 

Late Signs of Cancer. — Late signs of cancer interest us only in so 
far as they indicate whether or no the disease has passed a stage 
where operation may be attempted with hope of a favorable result. 
They are: pain, a discharge of blood from the nipple, ulceration,- 
skin metastases, metastases in other organs, enlarged supraclavic- 
ular glands, and cachexia. 

Discharge from the Nipple. — Besides being found in late cancer, 
a discharge from the nipple is present in the following conditions: — 
during pregnancy and lactation, in the infantile breast, in senile 
parenchymatous hypertrophy, and in papillomatous cysts. In 
the last case it is apt to be bloody. 

Ulceration of the Skin over the Cancerous Growth. — This is a very 
grave sign and few, if any, patients presenting ulceration have 
been cured by operation. 

Skin Metastases. — Occasionally two or more shot-like bodies are 
found in the skin of the breast at a distance from the malignant 
tumor. These are metastases from the tumor and are of serious 
import, for no case of permanent cure where skin metastases were 
present has been reported. 

Metastases in other Organs. — These are always an indication of the 



554 DISEASES OF THE BREAST 

hopelessness of radical operation. M. H. Richardson has recently 
called attention (Jour. Amer. Med. Assn., May 15, 1909, Vol. LIL, 
p. 1556) to the importance of making a complete physical exami- 
nation in the case of mammary cancer, saying that he has twice 
opened the abdomen for abdominal tumors of doubtful diagnosis 
without examining the breasts; and in both cases there were ex- 
tensive cancerous infiltrations, which were metastatic from the 
breasts. He says also that any persistent cerebral or spinal symp- 
toms in cancer of the breast should lead to an examination of the 
nervous system for metastases in the cerebro-spinal axis, of which 
he has now seen many cases; and a persistent cough should call 
for an examination of the lungs to find metastases there. 

Enlarged Supraclavicular Glands. — Palpable enlarged glands 
above the clavicle are of grave significance, the most favorable 
statistics showing only 7.5 per cent of cures following operation 
where the sign had been present. In the opinion of many opera- 
tors, the presence of these enlarged glands places the patient in 
the list of the hopeless. 

Cachexia. — When the disease has reached the point where the 
patient's health has failed and anemia, constipation, anorexia, 
loss of strength, a yellow color of the skin, and other symptoms 
of derangement of bodily function are present, there will be found 
also metastases, lack of mobility of the tumor, — because of the in- 
volvement of surrounding structures, — and ulceration, and the 
prognosis is absolutely bad. 

In all cases of clinically doubtful diagnosis, it is not wise to make 
an exploratory incision into the tumor with the knife, or the hollow 
Mixter punch, because of the very great danger of autoinfection. 

If a tumor is of doubtful diagnosis it should be removed, the 
pathologist in attendance at the operation deciding, by means of 
sections of the tumor, the need of radical extirpation of surrounding 
structures. 



CHAPTER XXVIII 

THE DIAGNOSIS OF THE GYNECOLOGICAL AFFECTIONS 
OF INFANCY AND CHILDHOOD 

Importance of examining the-genitals, p. 555. The examination, p. 556. 

Anomalies, p. 557: Adherent prepuce, p. 557. Labial hernia, p. 558. 
Hydrocele of the labium majus, p. 559. Imperforate hymen, p. 500. Im- 
perforate rectum and anus, p. 561. Prolapse of the uterus, p. 562. Erosion 
of the cervix, p. 563. Precocious menstruation and precocious maturity, p. 
564. 

Diseases of the vulva and vagina, p. 566: Vulvo-vaginitis, p. 566; Simple 
vulvo-vaginitis, p. 566; Gonorrheal vulvo-vaginitis, p. 5G(>, Symptoms, 
p. 568, Diagnosis, p. 568; Tuberculosis of the vulva, p. 568; Diphtheritic 
vulvitis, p. 569. Gangrene of the vulva, or noma, p. 569. Sarcoma of the 
vagina, p. 570. 

Genital hemorrhages, p. 571 : Hemorrhage from the vulva in the new- 
born, p. 572. Hemorrhage from the vulva in little girls, p. 572. 
Metrorrhagia of puberty, p. 573. 

Masturbation, p. 574. 

Malignant disease of the uterus, p. 576. 

Diseases of the ovaries and tubes, p. 576: Diagnosis, p. 576. 

Diseases of the bladder, p. 578 : How to collect the urine in infants, p. 578. 
Peculiarities of urination, p. 578. Enuresis, p. 578. Bacterinria. p. 579. 
Cystitis and stone in the bladder, p. 581. Primary tumor of the bladder. |>. 
582. Hematuria, p. 583. 

Diseases of the rectum, p. 584 : Prolapse of the rectum, p. 584. Proctitis, 
p. 585. Fissure in ano, p. 585. Incontinence of feces, p. 585. 

With the march of progress the gynecological affections of chil- 
dren that were formerly thought to be so infrequent as to merit 
little attention, are now known to be not only not rare, but of con- 
siderable importance from the standpoint of prophylaxis, if from 
no other. Practically all the diseases found in tin 1 adult have now- 
been observed in children. It IS a well-known fact thai the genitals 
of the female infant are n< »1 so carefully looked after by the physician 
and nurse as are those of the male child. Abnormalities of the 
prepuce in the latter are almosl always noted, while Hie vulva ol 

the little girl is not systematically inspected. Neglecl of abnor- 
malities and disease in the female infant -such, for instance, asaD 
insufficient opening in the hymen, adhesions of the aymph©, or 
vulvo-vaginitis— provide in later years for retained menses, or in- 



556 INFANCY AND CHILDHOOD 

fection of the genital tract, enuresis, masturbation, or salpingitis, — 
or for uterine malpositions, which are the result of previous pelvic 
peritonitis. The relatively frequent occurrence of sarcoma of the 
vagina in infants, its rapid and fatal course, make delay in diagnosis 
especially dangerous. Also, diseases of the urinary organs are by 
no means rare and deserve prompt attention. 



EXAMINATION 

The examination of the genital organs in children varies from 
that in adults in that the anatomical parts are very much smaller 
and the little patient's attention has to be distracted and her good- 
will obtained in greater measure before 
the investigation can be carried through. 
The use of an anesthetic becomes neces- 
! sary more often in the case of children 
than in adults, in order to secure the 
essential relaxation. A digital examina- 
tion of the vagina should seldom be at- 
tempted in children. If the vagina is 
| to be examined it must be inspected 
through a Kelly cystoscope of the largest 
size that will enter the vagina without 
rupturing the hymen ; artificial light and 
_^___ A a head mirror being employed as de- 




Fig. 203. -The Infantile scribed in the chapter on the investiga- 
Vulva. (Williams.) tion of the bladder (Chapter VIII., page 

110). The knee-chest position is the 
best posture for the examination. (See Fig. 205.) 

The recto-abdominal touch (see Chapter V., page 53) is the 
one to be employed in palpating the pelvic organs in children. 
For this an anesthetic is generally necessary in the case of very 
young children, but in older children, if their confidence can be 
gained, ether may not be required. The utmost gentleness and 
delicacy of touch must be employed in making palpation because 
of the relatively small size of the sphincter ani and the friable 
nature of the rectal wall in infants and children. The sad accident 
has occurred of the examining finger making a rent through the 



ANOMALIES 557 

rectum into the peritoneal cavity because too much force was used. 
Because of the relatively greater length of the examining finger 
and the small size of the pelvis and the close proximity of the 
abdominal organs, it is possible in little children to palpate the 
iliac, hypogastric, and umbilical regions through the rectum, and, 
in addition to the pelvic organs, in this manner to feel a diseased 
appendix or enlarged mesenteric glands. Be on the lookout for 
a full bladder, which is an abdominal organ in the child, and may 
simulate a cystic ovarian tumor or a collection of pus. 



ANOMALIES 

The development of the external genital organs is described in 
the chapter on the diseases of the vulva (Chapter XXI., page 392) 
and the reader is advised to consult this description and Figs. 
158 to 162, page 395, also Fig. 71 (from Kollmann), page 198, show- 
ing the development of the ovaries, tubes, uterus, and vagina, before 
taking up the congenital affections seen in children. Fig. 204, 
page 558, after Webster, shows the anatomy of the pelvic organs 
in the new-born child. Note that the vagina is relatively long, 
the cervix is long compared with the body of the uterus, and the 
uterus is in a position of retroposition with anteflexion, besides 
being high in the false pelvis. 

The congenital anomalies of the vulva, vagina, uterus, tubes, 
ovaries, — also of the bladder and rectum, are treated at length in 
the chapters devoted to these subjects. In the present chapter we 
will consider only those defects of the generative organs that cause 
symptoms during childhood and with which the practitioner must 
be familiar. 

Adherent Prepuce. — Adhesion of the prepuce to the clitoris with 
retained smegma is a not uncommon condition in female infants 
and children. Some; authors consider that the prepuce is adherent 
normally. W. A. Edwards (supplement to Keating's "Cyclopedia 
of Diseases of Children," p. 872) noted adhesions of the labia 
minora nine times in his private records of the births of two hundred 
and fifty female children. He says further thai he has been accus- 
tomed to see several cases of adherent prepuce in children every 
year. It is doubtful whether adherent prepuce is often a cause of 



558 



INFANCY AND CHILDHOOD 



grave nervous disease, but this acts sometimes as a cause of local 
irritation and of enuresis in children. In cases of wetting of the 
bed the genitals should be inspected carefully to rule out this 
abnormality. The irritation caused by the adhesion of the prepuce 
is thought to be a cause of masturbation, — at any rate the 
prepuce is often found adherent in masturbators. 

Labial Hernia. — An inguinal hernia sometimes passes along the 
round ligament and appears in the labium ma jus. This condition 




Fig. 204. — Longitudinal Median Section of the Pelvis of a New-born Child. 
(After Webster.) Showing relatively long cervix and vagina, retroposition 
with anteflexion, straight sacrum and cartilaginous coccyx. 

is seen in late childhood occasionally, and not rarely in infants. The 
hernial sac may contain omentum, intestine, or ovary and tube. 
Hernia of the ovary, sometimes accompanied by its tube, has been 
met fairly often in female infants under eighteen months of age, it 
being due apparently to the normal position of the ovaries and 
tubes in infancy close to the internal openings of the inguinal 
canals (sec Fig. 206), to a patent canal of Nuck, or a shortened 
round ligament. ,,The protrusion can be traced to the external 
abdominal ring above, and is limited to the upper portion of the 



ANOMALIES 559 

labium. If it contains omentum it is irregular to the feel and flat 
to percussion, and if intestine it is smooth and has a tympanitic 
note. The sac is generally reducible by taxis if the patient is re- 
cumbent unless it contains an ovary, when it is firmer, flat on per- 
cussion, tender, and can not be returned to the abdominal cavity. 
Labial hernia is to be distinguished from hydrocele of the labium 
majus and tumor of the labium. 

Hydrocele of the Labium Majus. — Should the peritoneal invest- 




Fig. 205.— Examination of the Infantile Vagina and Cervix with a Kelly Blad- 
der Speculum. (Kelly.) 

ment of the round ligament extend downward nearly to the end 
of the ligament in the labium instead of terminating as normally 
in the inguinal canal, this sac of peritoneum (the canal of Nuck) 
may become filled with serum, thus forming a hydrocele. In this 
case there is a firm ovoid tumor in the labium with its smaller end 
upward. It can not be reduced, it is Hat on percussion, and its up- 
per pole Is generally separated by an appreciable distance from the 
external abdominal ring. If the hydrocele is of large size, fluctua- 



560 INFANCY AND CHILDHOOD 

tion may be made out. The condition is a rare one and is dis- 
tinguished from labial hernia in not being reducible and in 
presenting a flat percussion and fluctuation. The differentiation 
from a tumor of the labium may be impossible. Tumors are apt to 
be in the lower part of the labia and they are of even rarer oc- 
currence. 

Imperforate Hymen. — Imperforate hymen, as pointed out in 
Chapter XXI., page 396, is a misnomer, the condition being gener- 
ally one of atresia of the lower part of the vagina. It is rare and 
generally causes no symptoms until menstruation is established. 
The results of not recognizing it until puberty are so deleterious 
to the patient that the obstetrician should satisfy himself by a 
careful examination of the genitals of every new-born girl, not 
only that the hymeneal opening is not closed, but that it is of suffi- 
cient size to afford proper drainage to the vagina. For, if it is not, 
infections and inflammations are more likely to occur in later 
years. This point can be determined easily by passing a catheter 
into the vagina. If the catheter will not pass, a proper opening 
into the vagina should be established by operation. 

The physician will do well to bear in mind that atresia of the vulva 
and vagina arises in many cases from the infectious diseases and 
is not, as formerly taught, "congenital." An apparent trifling 
infection of the genitals in childhood, accompanied by minor symp- 
toms, may result in closure of the vaginal opening or a gluing 
together of the nymphse. Therefore, the physician should watch 
his female infants and girls who are suffering from typhoid fever, 
smallpox, scarlatina, and diphtheria, with great care, having this 
possibility in mind. As pointed out by Nagel in 1896, it is rare to 
find true congenital atresia of the vagina except in cases where 
there is also present some arrest of development of the uterus or 
ovaries. 

L. Pincus (Monatsschr. fur Geb. und Gyn., 1903, XVII., p. 751) 
has maintained that a majority of cases of primary absence of the 
menses, supposed to be due to congenital obstruction of the vagina, 
are really caused by atresia of the vagina accompanying or follow- 
ing the infectious diseases, and he has reported cases which bear 
out his contention. According to him and contrary to common 
belief, typhoid fever is the most frequent cause of atresia, and 
H. A. Kelly (" Medical Gynecology," page 248) has collected nine 



ANOMALIES 561 

cases from the literature in which typhoid fever was the cause of 
vaginal atresia. Smallpox, as we might expect from the nature 
of the disease, comes next in frequency, and cases are reported of 
atresia following dysentery, pneumonia, erysipelas, cholera, scar- 
latina, and diphtheria. Attention has been called to this subject 
only in recent years so that the number of reported cases is not 
as yet large. 

To overlook atresia in a child is an easy matter, therefore the 
importance of instituting a minute inquiry as to the presence of 
vulvar irritation or discharge in a female child suffering from an 
infectious disease is apparent, and in the presence of atresia in 
children of more mature years the mother should be questioned 
as to whether these symptoms had existed during or following 
infectious disease in the child in the past. 

Imperforate Rectum and Anus. — Starr (" American Text-Book of 
Diseases of Children") has estimated that malformation of the 
rectum and anus occurs about once in ten thousand births and is 
more common in girls than in boys, — if we include anus vaginalis. 
As has been pointed out elsewhere (see Chapter XXVI., page 495) 
the rectum and anus are developed from entirely different struc- 
tures of the blastoderm — the former from the hind-gut, the latter 
from the proctodeum — therefore malformation of one does not 
necessarily imply abnormality of the other, and observations show 
that where the rectum is malformed or displaced the anus is com- 
monly normal, and vice versa. 

Imperforate Rectum. — Imperforate rectum is comparatively 
common, the rectum ending in an open tube on a level with the 
reflection of the peritoneum on the rectum, due presumably to the 
failure of the hind-gut to send out a bud (the post-allantoic gut) 
to meet the proctodeum. The imperforate rectum may open into 
the vagina, and in this case, unless imperforate hymen is present 
also, there is an escape of meconium or feces by the vagina. 

Imperforate Anus. — Imperforate anus, due to failure of develop- 
ment of the proctodeum, is a not uncommon anomaly. There 
may be no trace of the anus, or its situation may be marked by a 
slight depression or by a wart-like prominence. 

Imperforate anus with anal canal ending in the vulva is common 
and is confounded with imperforate rectum having a vaginal outlet. 
Incontinence of feces is generally present in these cases. 



562 



INFANCY AND CHILDHOOD 



Anus well formed and the anal canal ending above in a cul-de-sac 
is not uncommon. In this anomaly the child on straining causes 
the septum dividing the rectum from the anal canal to protrude 
from the anus. 

The obstetrician should examine the anus of every new-born 
child with a view to discovering the abnormalities just described. 
His little finger well anointed and introduced through the sphincter 
ani will go a long way toward finding an anomaly before it has 
caused serious symptoms. A thorough examination must be 




Fig. 206.— Pelvic Organs of a Female Infant at Birth. (After Bland- 
Sutton.) Showing elongated ovaries and the Fallopian tubes in close relation 
with the internal abdominal rings. 

instituted in case a baby has not had a movement of the bowels 
within twenty-four hours after birth and in case there is incontinence 
of feces. 

Prolapse of the Uterus. — Prolapse of the uterus in a new-born 
child is a rare condition. Ballantyne and Thompson (Amer. Journ. 
Obstet.j 1897, Vol. II., p. 35) reported eight cases from the literature 
and their own experience. The anomaly seems to be associated 
with lumbo-sacral spina bifida and rectal prolapse, — often with 
club-foot and sometimes with hydrocephalus, so that it may be 



ANOMALIES 563 

regarded as one of those congenital malformations that occur in 
children destined to have a short life. Two cases are on record of 
prolapse in girls of thirteen, due in one case to a persistent cough 
and in the other to carrying heavy burdens. I have myself seen a 
case of prolapse in a stout full-grown virgin due to a chronic 
diarrhea with tenesmus. 

Erosion of the Cervix. — Congenital erosion of the cervix is a con- 
dition that would hardly excite the attention of the general prac- 
titioner unless it were accompanied by a persistent vaginal discharge. 
In such an event it may be recognized by speculum examination 
of the vagina. Leopold first called attention to the occurrence of 
erosions in babies and children in 1872. Fischel (Arckiv. filr 
Gynaekol, 1880, Bd. XVI., S. 192) found cervical erosions which 
he examined microscopically in four fetuses still-born at term, 
in two infants a few days old, in an infant fourteen days old, 
and in three infants three, four, and five weeks old, respectively. 
As a rule, the external os in these cases is found in the form of a 
narrow transverse opening amounting often to a split in the crown 
of the cervix. The opening is surrounded by a reddened, velvety 
area from three to four millimeters wide. Sometimes the eroded 
area extends higher up on the lateral surfaces of the cervix than 
on the anterior and posterior aspects, and in other cases the erosion 
is limited to the crown of the cervix where the cervix comes in 
contact with the posterior wall of the vagina. These observations 
of Fischel have been confirmed by later observers, notably, in our 
own country, by C. B. Penrose. He says (" Diseases of Women," 
sixth edition, p. 174): — " Erosion of this character has been found 
in a more or less marked degree in thirty-six per cent of new-born in- 
fants." It predisposes to erosion in the adult virgin and appeals 
to be due to lack of proper development of the external os, so thai 
the sharp line of demarcation between the squamous epithelium of 
the vagina] portion of the cervix and the cylindrical epithelium of 
the mucosa of the cervical canal is not formed, and the cervical 
mucosa appears on the crown of the cervix. The affection has no 
characteristic symptoms. In the girl of more mature years congen- 
ital erosion may cause a mucoid vaginal discharge, a sense of 
weight in the pelvis and perhaps backache. In this event the 
vagina should be inspected will) a small Sims speculum, or a large 

Kelly cystoscopy. 



564 INFANCY AND CHILDHOOD 

Precocious Menstruation and Precocious Maturity. — Genital hem- 
orrhage in the new-born does not constitute precocious menstrua- 
tion. A flow of one to five days' duration must recur at regular 
intervals and be attended by various feelings of discomfort anal- 
ogous to those experienced by women at the catamenia, in order 
to be classed as premature menstruation. V. Gautier (Rev. meal, 
de la Suisse romande, 1884, IV., p. 501) reported twenty-four cases 
of this affection and Dr. John Lovett Morse (Archives of Pediatrics, 
1897) had brought the number of reported cases up to thirty-five 
in 1897. In this series the first flow began all the way from one 
week after birth to the seventh year, and regular menstruation 
persisted from three months to five and a half years. Numerous 
cases have been reported since. Precocious maturity involves a 
rapid growth of the whole body in height and weight, also changes 
in the size and shape of the genital organs and mammary glands, 
the growth of hair about the genitals and in the axillae, and regular 
menstruation. In older children who are instances of precocious 
maturity there is generally noted by the parents a marked pre- 
dilection of the child for the opposite sex. 

Menstruation is rarely the first symptom observed, in precocious 
maturity, but follows the changes in body development already 
noted. Gautier and Morse (loc. cit.) collected together fifty-seven 
cases of tins condition and the literature has shown many instances 
since. Here is a case reported by C. Wischmann, of Norway (ab- 
stract in Zentralbl. fur Kinderheilk., 1904, 9, p. 46). The child 
was born September 4, 1899, and a discharge of blood from the 
genitals was first noted February 24, 1901. In the succeeding 
sixteen months twelve menstrual periods were observed. The 
child was large, the breasts were full, and the mammary glands 
well developed. There was hair on the mons veneris and in the 
axillae. There were no evidences of rickets and there was no his- 
tory of similar abnormalities in the family. 

Dr. Morse, (loc. cit.) reported a case which I saw and examined 
for him on November 9, 1896, when the child was fourteen and a 
half months old. The facts in the case were briefly these:— The 
child was born August 29, 1895, and was said to have weighed 
fourteen poundsat birth. At that time her breasts were large and 
the baby was very fat in the neck. There was no history of early 
menstruation in the family except that the mother began to men- 



ANOMALIES 



565 



struate at twelve. One previous child, a boy three years old, was 
normal in every respect. When two months old the mother noticed 
that the baby had the " whites" and that there was a little coarse 
hair on the vulva. On May 29, 1896, when exactly nine months 
old, a bloody vaginal discharge was noted. Weight then was 
twenty-eight and a half pounds, — breasts large, mons veneris 
prominent, and external genital organs well developed. A flow 
of three clays, recurring each month, occurred regularly until she 
was examined November 9, 1896, and a leucorrhea was noted 




Fig. 207. — A Case of Precocious Maturity. 

months old. 



Child fourteen and a half 



during the intermenstrual period. There were no evidences of 
immodesty or sexual feelings. Then her appearance was that of 
a child of three, — weight thirty-six pounds, height thirty-two 
and a half inches, two teeth, intelligence above the average, and 
could say several words distinctly and walked well, — a moderate 
growth of hair in the axillae and on the back, breasts prominent 
and each contained a mass of gland tissue as large as a pigeon's 
egg, nipples well developed and surrounded by a dark areola and a 
little hair. Local examination showed: (I quote from my notes 
made at the time) "the labia majora well developed and meeting 
in the median line, a spare growth of light brown coarse hair on the 



566 INFANCY AND CHILDHOOD 

mons veneris and outer surfaces of the labia majora, labia majora 
well developed and of moderate size, clitoris normal, hymen with 
central opening dilatable, easily admitting my little finger, which 
is nine-sixteenths of an inch in diameter, for a distance of one and 
a half inches in the vagina, ruga? of vagina normal and cervix well 
formed, and of normal density. Vagina as large as that of a girl of 
six years." 

DISEASES OF THE VULVA AND VAGINA 

Vulvo- Vaginitis. — In discussing imperforate hymen and atresia 
of the vagina, vulvo-vaginal inflammation — more particularly 
the kinds of inflammation that attend the infectious diseases — 
has been referred to as a cause of atresia. 

Simple Vulvo-Vaginitis. — Epstein has described a form of vulvo- 
vaginitis that is present in fetal life and continues after birth. It 
is characterized by an abundant, glairy mucoid and muco-purulent 
vaginal discharge, and by redness and excoriation of the genitals. 
In the secretion are found much epithelium, leucocytes, and many 
forms of bacteria, — notably the streptococcus and frequently the 
bacillus coli communis, but never the gonococcus. By the bacte- 
riological examination this rare affection is distinguished from the 
common gonorrheal vulvo- vaginitis. Many authors have described 
a non-gonorrheal vulvo-vaginitis occurring in infants and children 
of all ages. It is due in some cases to masturbation. In these 
cases the discharge is more apt to be mucoid or muco-purulent 
than purulent — unlike the gonorrheal form — and the disease is 
not so rebellious to treatment as in the case of gonococcus infection. 
Mendes de Leon (abstr. in Jahrb. fur KinderheilL, 1908, Vol. 67, 
p. 253) thinks that the staphylococcus plays a role in the etiology of 
a simple vulvo-vaginitis in children and that this form of inflamma- 
tion is contagious, as in the case of the gonococcus form. 

Gonorrheal Vulvo-Vaginitis.— Of late years, since the discharge 
coming from the genitals of children who are affected with inflam- 
i mm lion in that region has been examined microscopically, the fact 
lias become painfully apparent that a majority of the cases of 
vulvitis are caused by the gonococcus. Of course the gonorrheal 
Form is met more often in dispensaries and in hospital clinics than 
i" private practice. Epidemics of the disease have occurred where 



DISEASES OF THE VULVA AND VAGINA 567 

all cases started from one child, such as that in the Babies' Hospital 
in New York in 1902 reported by L. Emmett Holt (New York 
Medical Journal, 1905, Vol. 81, p. 521). Another evidence of 
indirect and accidental infection is an epidemic which occurred in 
the city of Posen, Germany, in 1890, when two hundred and 
thirty-six school girls aged from six to fourteen years, were 
taken ill with vulvo-vaginitis in from eight to fourteen days 
after using the same public bath-house, where, on account of 
limited accommodations, the children were required to bathe in 
the same tub. Sometimes the infection is intentional, due to the 
superstition prevalent among some of the ignorant classes, that a 
man may rid himself of gonorrhea by giving it to a virgin. 

According to the published statistics of dispensary services, the 
disease is most frequent in the new-born and during the first five 
years of life, — then it is frequent again just before puberty. There 
is reason to believe that in a good many cases the infection has 
been transmitted to the child intentionally. To show the frequency 
of vulvo-vaginitis among the children seen in out-patient clinics, 
we may cite those of the Mount Sinai Hospital in New York, as 
given by Sara Welt-Kakels (New York Medical Journal, 1904, Vol. 
80, p. 689). During the ten years from 1893 to 1903 she saw 190 
cases of vulvo-vaginitis, forming one and six-tenths per cent of all 
the children seen. In the Women's Venereal Department of the 
Johns Hopkins Hospital Dispensary, 139 cases of vulvo-vaginitis 
were seen among 1,366 patients, or ten and two-tenths per cent 
(" Medical Gynecology," p. 365). These, of course, were in venereal 
cases only. Most authors regard the frequency of vulvo-vaginitis 
among sick children as about one per cent. 

The disease may be acquired from the mother during birth, and 
O. Heubner ("Lehrbuch der Kinderheilkunde," 1906, p. 502) 
has observed a case where an infant infected with gonorrheal 
ophthalmia subsequently became infected in the vulva, because of 
the carelessness of the nurse, and had a vulvo-vaginitis and a ure- 
thritis. This author thinks that in cases of vulvo-vaginitis in the 
child investigation will show that in many instances the mother 
will be found to have had a chronic leucorrhea. The use of the 
same towels, linen, and sponges by several members of a family may 
be the means of spreading the infection and of course the soiled 
fingers of the nurse or the mother are accountable in many cases. 



INFANCY AND CHILDHOOD 

Symptoms of Vulvo-Vaginitis.— The symptoms of vulvo-vaginitis 
may excite little attention. In the case of a baby it may cry on 
passing water and an older child may complain of smarting on 
micturition. There may be itching or burning at the vulva so that 
the child scratches. In a few cases Bartholin's glands are swollen, 
but they do not suppurate. The inguinal glands may be swollen, 
but a bubo is not formed. If attention is called to the disease in its 
initial stage the body temperature will be found to be elevated. 
Often the mother brings the child to the physician because its 
linen is stained with yellow spots. In cases of long standing the 
child becomes pale and its general health suffers. The disease 
most often gets into the chronic stage before it is discovered and it 
runs a chronic course of weeks and months and is extremely re- 
bellious to treatment. One author has reported finding gonococci 
in the discharges after the disease had existed for four years. W. 
J. Butler and J. P. Long (Journ. Amer. Med. Asso., Oct. 17, 1908, 
p. 1301) state that in their experience in institutional epidemics 
of vulvo-vaginitis in children during ten years, the disease is 
quite as intractable to treatment as in adult women. 

Diagnosis of Vulvo-Vaginitis. — On separating the labia the 
entire vulva is found to be red. It is wiped with a pledget of ab- 
sorbent cotton and by pressure on the perineum from behind, pus — 
generally of a greenish color — comes from the vagina and the 
urethra. The physician should not introduce his ringer into the 
rectum in cases of suspected infection of the genitals because of 
the very great danger of introducing infective matter in that organ. 
Cover glasses are prepared from the pus for microscopic examination 
as described on page 61. Usually the gonococci are easily demon- 
strated in the cells by the Gram method. The disease is differ- 
entiated from simple vaginitis by the bacteriological examination. 
Very rarely injuries of the vulva are found and only then are we 
justified in diagnosing rape. The inflammatory symptoms gen- 
erally last from four to six weeks and the discharge changes from 
profuse purulent to scanty and mucoid as the disease progresses. 
The most frequent complication seems to be arthritis. Gonorrheal 
peritonitis has been reported as a sequel of gonorrheal vulvo- 
vaginitis by at least twelve different authors, therefore it may 
be regarded as a serious complication. 

Tuberculosis of the Vulva— Whether tuberculosis of the external 



DISEASES OF THE VULVA AND VAGINA 569 

genitals is ever primary in those organs seems to be doubtful. 
Briining, according to Langstein (Pfaundler and Schlossmann, 
"Diseases of Children"), collected forty cases in which the disease 
seemed to start in the tubes, and then affected in order, — the 
ovaries, uterus, vagina, and vulva. He is of the opinion that 
primary tuberculosis of the external genitals has not been proven 
because the diagnosis in the cases reported has been made clini- 
cally, whereas definite pathological proof of the absence of tuber- 
culosis elsewhere in the body is necessary before deciding that the 
disease has originated in the vulva. 

We are safe in saying that primary tuberculosis of the genital 
organs in children usually originates in the Fallopian tubes and 
from this situation is transmitted to the other organs of the genital 
tract. The disease is commonly secondary to tuberculosis of the 
lungs. In any event it is a rare affection. Secondary tuberculosis 
of the pelvic organs is seldom recognized in young children, the 
symptoms being masked by the symptoms of the primary pul- 
monary lesion. The appearances and the diagnosis are described 
in Chapter XXI., page 408. 

Diphtheritic Vulvitis. — Diphtheria of the vulva, secondary to 
pharyngeal diphtheria, is an occasional disease of childhood. Several 
cases of primary diphtheria of the vulva have been reported. Jacobi 
(Archives of Pediatrics, Feb., 1891) reported firm occlusion of the 
vulva and vagina as a result of diphtheritic inflammation, and 
Hydrup-Pederson, according to W. A. Edwards, reported the case 
of a girl of fifteen, who during an attack of diphtheria passed a 
complete cast of the vagina. Later the child developed a marked 
atresia of the vagina which was cured by operation. Diphtheritic 
vulvitis is characterized by swelling, dark red discoloration, and 
the formation of a thick gray membrane covering, and adherent 
to the tissues. Constitutional symptoms of fever of moderate 
degree, anorexia, and pallor with loss of strength are present. The 
membrane separates from the underlying tissues in the course of a 
few days, leaving an ulcerated surface, and there is a foul-smelling 
vaginal discharge. The Klebs-Loefner bacillus is found in the 
discharges or in smears made from the affected parts. 

Gangrene of the Vulva, or Noma Vulvae. — Gangrene of the vulva, 
a disease similar to cancrum oris, may attack the vulva (usually 
one of the nympha)), in the case of dirty and underfed children, 



570 INFANCY AND CHILDHOOD 

or as a complication or sequela of measles, scarlatina, erysipelas, 
or typhoid fever. The disease is not so common as it was formerly, 
especially in hospitals, because of the improved hygienic surround- 
ings and aseptic treatment. Noma of the mouth is often associated 
with noma of the vulva. For instance, Gierke reported thirteen 
girls in his hospital service in Stettin, with noma of the mouth, 
four of whom also had noma of the external genitals. Loeschner, 
in the babies' hospital in Prague, noted two cases of noma of the 
vulva among twenty cases of noma of the mouth. The disease 
begins usually as a livid red, indurated swelling of one labium, 
soon breaking down into dirty gray or dull red ulcerations and 
followed by a greenish-black layer of gangrene. The constitutional 
symptoms are severe and the disease, though rare, is a serious one. 

Sarcoma of the Vagina. — Sarcoma of the vagina is by no means 
a rare affection in children. Although there are only forty or so 
authentic cases reported in the literature, there have been numerous 
cases of polyp of the vagina reported without microscopic exami- 
nations of the tumor. Now, polyp of the vagina is a morbid con- 
dition in children that is unknown to the pathologist. The known 
new growths of the vagina besides sarcoma are, — cysts, myoma, 
carcinoma, venereal warts, and the extremely rare primary chorio- 
epithelioma. All of these except sarcoma occur almost always in 
adults, and this occurs in both adults and children. Pedunculated 
primary myoma of the vagina might be mistaken for sarcoma, 
but of the seventy cases of myoma reported only one or two oc- 
curred in the child. Edwards has been able to find no case of 
primary carcinoma in the child, but he cites two cases of primary 
chorioepithelioma of the vagina, in children thirteen and twelve 
years old, respectively. I think these should be viewed with sus- 
picion as yet, until further observations have been made. There- 
fore we must consider the cases of vaginal polypi so frequently 
referred to in the literature as instances of sarcoma, until the con- 
trary has been proven. 

Sarcoma of the vagina in children generally develops in the first 
year of life and is fatal within a year or two. In most cases it ap- 
pearsto be present at birth. Demme-Granicher (L. Pick, Archiv 
fur Gynaek., 1894, 46,218) reported the case of an infant in whom 
a nodule the size of a pea was found in the vagina at the time of 
Mill). This showed no signs of active growth until the sixth year, 



GENITAL HEMORRHAGES 571 

when it increased rapidly and the child died in the seventh year, 
of fibrosarcoma of the vagina. Other instances go to show that 
the disease may be latent just as in this case, so that should a tumor 
of the vagina be discovered, the practitioner will err on the side of 
safety if he removes it and submits it to a microscopic examination. 

Sarcoma of the vagina is characterized by the development of a 
mass of vesicle-like polypi of a dark red (hemorrhagic) and pinkish- 
gray (translucent) color, arranged in racemose clusters. The first 
evidence of the disease is what appears to be a polyp similar to a 
mucous polyp of the uterus. This generally springs from the 
anterior wall of the vagina, though a certain proportion (perhaps 
a quarter of the cases) have been found on the posterior wall. This 
primary tumor, when it grows, proliferates rapidly in the form of 
the racemose polypi and soon fills the vagina. The base of the 
tumor becomes broader and infiltrates the vaginal wall, the disease 
tending to invade the bladder early, — probably because it begins 
in close proximity on the anterior vaginal wall, — then the cervix 
and uterus, — next the parametrial cellular tissue with the uterus 
(causing hydronephrosis), and finally the peritoneum. The disease 
progresses rather slowly, seldom extends to the rectum, and me- 
tastases to distant organs are infrequent. Therefore, prompt 
recognition and removal offer a good chance for permanent cure. 
Histologically sarcoma of the vagina may represent all the different 
varieties of sarcoma. 

The diagnosis before the disease has progressed extensively is 
very difficult. A vaginal discharge in an infant, or the presence of 
any tumor in the introitus vaginae, should lead at once to an ex- 
amination with a Kelly cystoscope, followed by the prompt removal 
of adventitious tissue for microscopic examination. 



GENITAL HEMORRHAGES 

As previously stated, hemorrhage from the vulva does not con- 
stitute precocious menstruation. Hemorrhagic disease of infants 
or children, or hemophilia, is an inherited taint characterized by 
bleeding on slight trauma or spontaneously from any of the cavi- 
ties of the body that are lined with mucous membrane, — the nose, 
the mouth, the intestines, the stomach, and other organs. It is 



572 INFANCY AND CHILDHOOD 

generally not manifest before the second year and an attack of 
bleeding is usually accompanied by fever, and hemorrhage takes 
place from several situations. In purpura also, hemorrhage may 
take place from the genitals as well as from other mucous mem- 
branes. This disease is apt to occur in cachectic, rachitic, or anemic 
children and is commonly observed between the second and the 
tenth year. Here also fever is present and the bleeding is from 
several sources. These diseases have nothing to do with the dis- 
ease about to be described. 

Hemorrhage from the Vulva in the New-born. — The occurrence 
of this affection in infants who were not the subjects of hemo- 
philia or purpura, was observed thirty-five times in ten thousand 
female children by Schulkowski, and Cullingworth saw thirty-two 
cases in children under six years of age. J. Zappert (Wiener med. 
Woch., 1903, No. 31) had observed occasionally a bloody mucoid 
discharge from the vulva in new-born girls from the fifth to the 
sixth day after birth. There were no attending symptoms such as 
pain, and the discharge was of short duration, did not recur, and 
seemed to be entirely harmless. Zappert was enabled to examine 
a portion of a uterus from a child who had typical hemorrhage of 
this kind. The genitals appeared to be normal and there had been 
no previous sepsis. Microscopic examination of the portion of the 
uterus showed only excessive vascularity of the submucous tissue 
and extravasation of blood corpuscles from the dilated vessels, 
but an intact epithelium of the mucous membrane and an absence 
of all traces of inflammation, — an analogous condition, in other 
words, to the histological picture of the endometrium of the men- 
struating uterus in the adult. Like the swelling of the mammary 
glands often noticed in the new-born, this hemorrhage may be due 
to some physiological stimulation of the uterine mucous membrane. 

In Schulkowski's observations the hemorrhage did not appear 
until the fifth or sixth day after birth and he considers that the 
cause of the hemorrhage is a physiological hyperemia of all the 
abdominal organs that is present soon after birth. 

Hemorrhage from the Vulva in Little Girls.— J. Comby ("Traite 
des Maladies de L'Enfance," 1897, p. 554) insisted that a local 
cause was to be sought for vulvar hemorrhages in little girls, and 
this view is in accord with the facts as to the post-climacteric 
hemorrhages. Although in the latter case investigation of the 



GENITAL HEMORRHAGES 573 

genitals is usually attended by less difficulty, we should not be 
deterred from instituting a thorough examination in infants in 
case the bleeding is persistent, or recurs. Comby has noted hem- 
orrhage from the vulva in children who are the subjects of vulvo- 
vaginitis and he cites A. Broca, Pourtier, Henoch, Heinricius, and 
Graefe, each as having found prolapse of the urethral mucous 
membrane a cause of genital hemorrhage in the new-born. The 
frequency of genital hemorrhage in the course of infectious dis- 
eases may well be due to inflammation in the vagina or uterus in 
these cases. Henoch noted hemorrhage in the case of "papilloma 
of the vulva or vagina." By this we should understand now, 
sarcoma of vagina or vulva, or possibly angioma, which has been 
reported by Sanger and others. Angiomatous tumors are said to 
degenerate rapidly and, in this event, might well, cause bleeding. 

Although a case of lipoma of the vulva in a five-months-old 
child (Quinn, Bull. Soc. de chir., 1890, Vol. 16, No. 1) has been 
reported, it seems improbable that such a tumor could be the 
cause of hemorrhage. Carcinoma of the vulva and vagina is un- 
known in new-born infants, although a few cases are on record of 
the disease in older children. 

Congenital erosion of the cervix, prolapse of the urethra, vulvo- 
vaginitis and its sequelae, also sarcoma of the vagina and prolapse 
of the mucous membrane of the urethra, should be kept in mind 
by the physician as possible causes of a bloody vaginal discharge. 

Metrorrhagia of Puberty. — The hemorrhages from the genitals 
that occur at the time of puberty may be of varied causation 
according to P. Hours (These de Paris, 1908) who reported fifteen 
cases. He enumerates the following as causes: — Fungous endo- 
metritis following infection from the vagina, uterine new growths, 
diseases of the heart, liver, or kidneys, chlorosis, hemophilia, 
purpura, the eruptive fevers, and finally and most frequent, the 
general infections and toxemias. The possibility that the nervous 
system, governor of the menstrual function, may not become adjusted 
at once and that hemorrhage as well as scanty menstruation may 
occur in girls at puberty without discoverable lesion of the genitals, 
should be in the physician's mind. But, on the other hand, he 
should not sit with hands folded and let " Nature" work out the 
problem unassisted. The rational procedure in all cases of vaginal 
hemorrhage is to make a local examination and try to find the 



574 INFANCY AND CHILDHOOD 

cause at first hand. Even if no local cause is found, the physician 
will treat his patient more understandingly with the knowledge 
that she has no manifest lesion of the genitals. 



MASTURBATION 

Masturbation (from the Latin, masturbare, to pollute one's self) 
is a much commoner condition in children than is generally thought 
by the profession. We must distinguish two sorts, — ;(1) that 
occurring in infants, called by B. K. Rachford " Pseudomasturba- 
tion," (Archives of Pediatrics, Aug., 1907, p. 561) and (2) true 
masturbation, occurring in older children. 

(1) Pseudomasturbation. — This has been described under the 
titles, — " Thigh Friction," and "Infantile Masturbation." It is 
accomplished generally by the child lying on its back, the thighs 
are flexed, crossed, and pressed tightly together, closely embracing 
the genitals. In this position the infant rubs its thighs together 
or makes up and down movements with its body. Sometimes 
it rubs itself against its mother, or the corner of the crib, or other 
foreign objects, seldom using its hands. The movements are 
evidently attended by pleasurable sensations, with nervous tension, 
excitement, flushing of the face, staring eyes and large immobile 
pupils, followed in a few minutes by perspiration, relaxation, con- 
tentment or exhaustion, and sometimes by sleep. This sort of 
masturbation occurs as early as the fourth month and the average 
age was sixteen months in the table of fifty-two cases reported by 
Rachford. He explains its early occurrence by the fact that the ex- 
ternal genital organs in the girl are practically fully developed and 
endowed with physiological function at birth, whereas the internal 
organs of generation do not attain their full growth until the child 
is ten years old. Partly on this account and partly because the 
infant can have no sexual thoughts, he thinks this sort of mastur- 
bation should be distinguished from the masturbation of older 
children and adults. Of the fifty-two cases collected by this author 
by eighteen different reporters, forty-eight were in female infants,— 
therefore the affection may be said to belong to the female sex. 
This can be explained on the ground of the proximity of the openings 
of the urinary and fecal canals to the sensitive vulva, and to the 



MASTURBATION 575 

fact that the clitoris, being less protected by the labia than in the 
adult, is more exposed to excitation and irritation by necessary 
handling in the interests of cleanliness. A hyperacidity of the 
urine existed in more than half of the reported cases. Therefore, 
this must be considered as a cause. Intestinal worms, proctitis, 
adherent prepuce, and uncleanliness must be reckoned as causative 
also. Heredity in the form of a neurotic inheritance, meaning an 
unstable nervous system in a poorly developed body, existed in 
three-fourths of the cases and L. Emmett Holt, in forty-six cases 
in his private records, was struck with the great frequency of 
masturbation in mentally defective children. 

(2) Masturbation in Older Children. — In older children the 
practice of masturbation is more commonly found in boys than 
in girls. The example of other children is an important factor in 
establishing the practice, and when the habit is once formed it is 
hard to break. 

As regards its effect on the child most authorities are agreed that 
it is deleterious, but not very serious in most cases unless practiced 
to excess. The vice is thought to be present in the nervously or 
mentally defective, and to accompany such conditions as a result 
and not as a cause. 0. Heubner has noticed derangement of the 
heart in masturbating children, especially idiopathic hypertrophy 
with dilatation, — particularly of the left ventricle, — and irregularity 
of action during violent exercise. Masturbating children with 
strong bodies show fewer symptoms than those with weak bodies. 
Edwards (loc. cit.) says that masturbating children often do serious 
damage to the sexual organs, citing Bokai's case in which a girl of 
ten, who for a long time had practiced masturbation, for the same 
purpose had ligated the clitoris so tightly with a thread that the 
organ swelled up to the size of an Italian hazel-nut. The thread 
was removed fourteen days later and it became necessary sub- 
sequently to remove the hypertrophied clitoris with the thermo- 
cautery. 

Sometimes children introduce foreign bodies into the vagina 
for purposes of masturbation, but this practice is not so common 
as in the case of adults. J. P. West, who has reported several cases, 
says: "A number of children who do not thrive after every care and 
attention has been given for every disease or trouble that could 
be found, will prove to be masturbators. I have seen many 



576 INFANCY AND CHILDHOOD 

illustrations of this and have been deceived not a few times by 
parents who were unwilling to acknowledge the practice of this 
habit in their child." 

If a child is addicted to this vice the diagnosis is established 
only by observing the practice. Abnormalities of the genital 
organs and of the urine should be excluded by a local examination 
and by urinalysis before measures of treatment are instituted. 



MALIGNANT DISEASE OF THE UTERUS 

Recent investigation of the literature by W. A. Edwards (Amer. 
Journ. Med. Sci., July, 1909) shows twenty-three reported cases of 
malignant disease of the uterus in children between nine months 
and fifteen years of age. Sixteen of these were primary sarcoma 
and seven carcinoma, three of the latter being cancer of the cervix. 
There were many varieties of sarcoma reported and the cases of 
sarcoma of both uterus and vagina where the point of origin of the 
disease was in doubt have been excluded in my summing up, — 
so also have been culled out a case of cancer of the abdominal or- 
gans and an encephaloid cancer in a young woman of eighteen. 
Therefore in the future it behooves us to be on the lookout for 
malignant disease even in the very young. 

DISEASES OF THE OVARIES AND TUBES 

Ovarian tumors are fairly common in children, especially the 
embryomata and cystadenomata. Bland-Sutton over ten years 
ago had collected one hundred cases of ovariotomy performed on 
children under sixteen years of age and Olshausen among one 
thousand seven hundred and sixteen ovariotomies has operated 
on children sixty-one times. Ovarian tumors, although found in 
infancy, become more frequent as puberty is approached. W. 
A. Edwards (loc. cit.) has recently collected forty-eight cases of 
malignant disease of the ovary in children fifteen years old or 
younger, the youngest being a fetus seven months old. Sarcoma 
of various sorts, or carcinoma was found in every case, sarcoma 
being the more frequent. There are many cases in the recent 
literature of primary tuberculosis of the tubes in children, and 



DISEASES OF THE OVARIES AND TUBES 577 

also of gonorrheal salpingitis from extension upward of the infec- 
tion of vulvo- vaginitis. Some of these last cases are attended by 
general peritonitis of a severe type. 

After the infectious diseases, as pointed out by Lebedinski, 
Skobansky, and others, there is a degeneration of the Graafian 
follicles of the ovaries just as there is degeneration in the other 
parenchymatous organs after these diseases. Therefore, the 
function of the ovaries is, for a time at least, more or less impaired 
by scarlet fever, typhoid fever, and diphtheria. Massin (Archiv 
fur Geb. and Gyn., 1891, XL., p. 146) showed that the uterus 
exhibited endometritis after typhoid fever, pneumonia, dysentery, 
and " relapsing fever " ; but Jung (Zentralb. filr Gyn. , 1904, XXVIII. , 
p. 991), after an exhaustive investigation of gonococcus infection, 
thinks that the gonococcus from vulvo-vaginitis seldom lurks in 
the cervical canal in children. 

Symptoms and Diagnosis. — On account of the small size of the 
child's pelvis there is an early ascent of an ovarian tumor into the 
abdomen ; in fact, the ovaries are abdominal organs in the infant. 
Therefore, pressure on the bladder and rectum is rarely present in 
the case of ovarian tumors in the child. On the other hand, a 
relatively small tumor, owing to the limited room for expansion, 
causes marked disturbances of digestion and respiration. The child 
is easily fatigued and, if old enough to call attention to her dis- 
comforts, may complain of pain in the abdomen. The watchful 
mother notices an undue prominence of the abdomen and that 
the child's appetite is impaired and her breathing short. 

The diagnosis of diseases of the ovaries and tubes in children is 
made by the bimanual recto-abdominal touch. It is well to first 
put the child in the knee-chest position and admit air into the 
rectum by passing a cystoscope or catheter through the anus. 
Great gentleness should be used in making the bimanual touch. 
Owing to the small size of the pelvis and the straightness of the 
sacrum in the child, a comparatively small tumor of the ovary 
may appear to be high in the abdomen and springing from the 
liver or kidney because of the small amount of space in the child's 
abdomen. An anesthetic should be used for the examination, 
perhaps only a few whiffs of ether or chloroform being given. 
Find first the position of the long cervix and short uterine body. 
In comparison to the body the cervix appears at first to be unduly 
37 



578 INFANCY AND CHILDHOOD 

large. It is high in the pelvis. (See Figs. 204 and 206.) The 
ovaries are like little cucumbers with their long axes corresponding 
with the long axis of the Fallopian tubes and they are close to the 
pulsating external iliac arteries ; also, the uterus being so high, the 
utero-sacral ligaments are arched in the shape of a bow and may 
be felt as guides to the ovaries. In the case of an ovarian tumor 
one ovary of course will be wanting. The cervix may be drawn 
down with a double tenaculum held by an assistant while the bi- 
manual touch finds and determines the length, breadth, and thick- 
ness of the pedicle of a tumor, just as in the adult. (See Fig. 126, 
page 301.) 

A discussion of the different sorts of tumors both of the ovaries 
and of the Fallopian tubes will be found in the chapters devoted to 
these subjects. Suffice it to say here that sarcoma of the ovary and 
tuberculosis of the tubes are rather more frequent in children than 
many of the other affections. 

DISEASES OF THE BLADDER 

Practically all the diseases of the bladder found in the adult are 
met with in children. The anomalies will be found in Chapters 
XXIII., XXIV., and XXV., pages 444, 457, 486. Here we will refer 
to some of the commoner affections. Prolapse of the mucous 
membrane of the urethra has been referred to in the section on 
genital hemorrhages. 

To collect the urine of a female infant place a small cup over the 
vulva and hold it in place with the napkin. If the infant is placed 
upon a chamber regularly every ten or twenty minutes for a few 
hours and a cold compress is placed over the bladder, urine may 
generally be obtained. Catheterization with a soft-rubber catheter 
under aseptic conditions is a certain and reliable means of getting 
a specimen of urine. 

The twenty-four-hour amount of urine in infants is relatively 
greater than in older children and adults. The urine is passed as 
often as twice an hour during the waking hours of the first two 
years of life, while during sleep it is retained from two to six hours. 

Enuresis. — The involuntary voiding of urine, especially at night, 
is a fairly common affection. The consideration of this subject 
belongs to the domain of neurology rather than gynecology, as 



DISEASES OF THE BLADDER 579 

the affection is due in a majority of cases to derangement of the 
nervous system. (See Chapter X., p. 154.) The involuntary dis- 
charge of urine is normal in the young infant and it becomes 
voluntary only at a later age and is dependent largely on the 
child's training. In most children the urine is controlled during 
the waking hours after the first year, but while asleep it may be 
passed in the bed as late as the second year, or even the third year, 
so that the loss of control during sleep should not be regarded as 
abnormal until the end of the third year. 

During five years at the Children's Dispensary of the University 
Hospital in Philadelphia, Ostheimer and Levi (Journ. Amer. Med. 
Asso., Dec. 17, 1904) found eighty-five cases of enuresis among 
one thousand, six hundred and fifty-seven new patients, or about 
five per cent. Townsend had one case of rectal polyp in a girl 
suffering with incontinence in which a cure was effected by re- 
moving the polyp. Ostheimer and Levi had a similar case in which 
cure was not obtained by removing the polyp. Kerley (Bost. Med. 
and Surg. Journ., Vol. CLV., pp. 172-174) noted the presence of 
urine of a high specific gravity and hyperacidity in the subjects of 
incontinence and assigned, as causative in some cases, contracted 
bladder, adhesions of the prepuce, vaginitis, and thread worms. 
Suffice it to say here that in case of enuresis the genital organs 
should be carefully examined to rule out abnormalities. 

Bacteriuria. — For the substance of this section I am indebted 
largely to Dr. John Lovett Morse's excellent article, "Infection 
of the Urine and the Urinary Tract by Bacillus Coli in 
Infancy" (Amer. Journ. Med. Sciences, Sept., 1909). 

Bacteriuria is a disease characterized by the presence of bacteria 
in exceedingly large numbers in the freshly passed urine, and by 
the absence of marked symptoms of an inflammatory process in 
the mucous membrane of the urinary tract. It must be remembered 
that the presence of bacteria in the urine in the course of an in- 
fectious nephritis, or in a general infectious disease, does not con- 
stitute bacteriuria. Bacteriuria is most common in infancy and 
is almost always due to the bacillus coli communis. Dr. Morse has 
seen fifty cases, over sixty per cent of them being in girls. Escherich, 
who in 1894 first pointed out the frequency of bladder affections 
in girls, observed that the bacillus coli was present fifty-eight 
times among his sixty cases. 



580 INFANCY AND CHILDHOOD 

There are, as a rule, no severe general symptoms in bacteriuria. 
There may be slight elevation of temperature and malaise. Fre- 
quent and painful micturition are not uncommon, and older children 
who are the subjects of this disease, often suffer from incontinence. 
The urine is uniformly cloudy, having the appearance of a bouillon 
culture of bacteria. The odor is foul and the reaction acid. 

Etiology. — Theoretically, infection of the urine and the urinary 
tract may occur in three ways: (1) Through the blood (the 
hematogenous, or descending theory); (2) Through the urethra, 
(the ascending theory), and (3) Through the tissues between the 
intestines, the home of the bacillus coli, and the bladder (the 
transparietal theory). Without going into a detailed analysis of 
these theories it is sufficient to note that they indicate that the 
route of infection is not always the same. It seems reasonable to 
conclude, however, that in the majority of the cases in girls the 
infection is through the urethra, in a fair proportion it is trans- 
parietal, while it is occasionally hematogenous. Infection of the 
bladder is impossible while the mucosa is normal; therefore some 
lesion or abnormality of this membrane is a contributory cause. 

Pathology. — Reddening or swelling of the mucous membrane of a 
whole or a part of the urinary tract with some desquamation of 
the epithelium, and, in some cases, evidences of degeneration of 
the lower tubules of the kidney, are the only pathological changes 
that have been observed in bacteriuria. The disease may be second- 
ary to disturbance of the intestinal tract; often the determination 
as to whether the internal disturbance is before, or after the bac- 
teriuria, is a difficult matter to settle. 

Symptoms and Diagnosis. — In a majority of cases the symptoms 
are: elevation of temperature, restlessness, drowsiness, fretfulness, 
and signs of discomfort. Anorexia is the rule, and disorder of 
function of the gastro-intestinal tract is especially common. Vomit- 
ing is not unusual and the movements of the bowels are abnormal. 
Frequent and painful micturition may be present if there is a cys- 
titis or urethritis, or tenderness in the kidney region if the kidney 
is involved. Often the staining of the baby's napkins yellow, by 
the turbid urine, first calls attention to the condition. 

Examination of the urine shows the urine to be pale and uniformly 
cloudy, the cloudiness being due in part to the bacteriuria and in 
part to the presence in the urine of large numbers of pus cells. 



DISEASES OF THE BLADDER 581 

Sometimes the urine has a gelatinous appearance. The odor may 
be normal, but it is generally foul. The specific gravity is not 
abnormal and the twenty-four-hour amount varies only with the 
amount of liquids ingested. The reaction is almost invariably 
acid and not infrequently strongly acid. The Bacillus coli does 
not decompose urea and thrives in an acid medium, though pre- 
ferring an alkaline or neutral medium. The acidity of the urine 
being hostile to the growth of other bacteria, the Bacillus coli is 
usually found in pure culture. The urine usually contains less 
than one tenth of one per cent of albumin and under the micro- 
scope the sediment is seen to be composed largely of pus cells, — 
usually single, sometimes in clumps. Caudate, small round cells, 
and squamous cells in small numbers are present in many cases, 
but squamous cells are never to be found in large numbers, as they 
are in purulent inflammation, — probably because of the absence of 
the ammoniacal products of the decomposition of urea, which are 
the cause of the destruction and desquamation of bladder epithe- 
lium in inflammatory affections of the bladder. Hyaline, or fine 
granular casts are seen occasionally, — blood almost never. The 
disease has been confused with typhoid fever and with malaria. 

Cystitis and Stone in the Bladder. — Cystitis, a true inflammation 
of the bladder, is now known to be of relatively frequent occurrence 
in female infants and little girls, though extremely rare in male 
infants. It is most often observed in the first three years of life. 
Stone in the bladder, on the other hand, occurs twenty times in 
the male to once in the female child. This is due, probably, to the 
short urethra in the female, offering not only opportunity for 
infection from without, but an easy escape for calculi from the 
bladder. Since Escherich called the attention of the profession to 
the frequency of cystitis in 1894, cases have been reported in the 
literature with ever-increasing frequency; probably many of these 
being cases of bacteriuria, however. 

The three theories as to the route of the infective bacteria in 
their course to the bladder, ascending, descending or hematogenous, 
and transparietal, have been referred to in the discussion of bac- 
teriuria. Cystitis is due in a majority of cases, just as with the 
last disease, to (a) the bacillus coli communis which reaches the 
bladder by any of the three ways, but generally through the urethra. 
It may be due to (&) the tubercle bacillus, and in this event the 



582 INFANCY AND CHILDHOOD 

process is almost always a descending one, the disease originating 
in the kidneys, or it is transmitted through the blood from the lungs 
or other focus, (c) Gonococcus infection of the bladder is a process 
ascending through the urethra; so is (d) a diphtheritic cystitis fol- 
lowing diphtheria of the vulva. The infections from (e) staphylo- 
coccus, or (/) streptococcus are generally secondary to suppuration 
in the kidney, but may come by either of the other two routes. 

Cystitis is present in some degree in practically every case of 
stone in the bladder, because the calculus inflicts trauma on the 
mucous membrane and thus makes possible infection; for, as we 
have stated previously, bacteria can not live in a bladder which is 
lined with a normal mucosa. 

Symptoms and Diagnosis. — The child is restless, cries a great deal, 
is pale and weak, has loss of appetite, and the temperature is ele- 
vated. There are increased frequency of micturition and difficulty in 
passing urine, also colic in the abdomen, with tenderness on press- 
ure over the bladder. The urine is generally acid, cloudy, and of 
strong odor. The sediment under the microscope is seen to contain 
much pus, free and in clumps, and many squamous epithelial cells 
from the bladder, also blood and bacteria. Through the cystoscope 
the mucosa is seen to be reddened, swollen, and covered with mucus. 
It may be excoriated and show ulcerations and clotted blood. In 
the tuberculous form there are fibrinous deposits on the surface 
of the mucous membrane and cultures made from the deposit 
determine the sort of bacterium present. 

Stone in the Bladder. — As already pointed out, this is rare in 
the female. There are certain parts of the United States where 
it is relatively common, such as Kentucky, Tennessee, Ohio, 
Virginia, and North Carolina. The calculi are mostly composed of 
uric acid. Next in frequency are oxalate of lime, and sometimes 
there is found urate of ammonium combined with uric acid. 

The symptoms are sudden stoppage of the stream of urine during 
micturition, vesical tenesmus, cloudy and strong-smelling urine, 
and, in older children, pain in the bladder region on jumping or 
playing violently. The diagnosis is made by passing the sound into 
the bladder and noting the metallic click caused by bringing it in 
contact with the calculus. 

Primary Tumor of the Bladder.— G. Husler (Jahrbuch fur 
Kinderheilk., 1905, Vol. 62, p. 33) has collected from the literature 



DISEASES OF THE BLADDER 583 

three primary tumors of the bladder in female infants aged, respec- 
tively four, nine, and seven months; the symptoms being a sudden 
retention of urine followed by cystitis with bloody urine. One of 
the tumors was a spindle-celled sarcoma, another fibroadenoma, 
and the third of unknown character. In the same list with these 
three cases were eleven instances of tumor of the bladder in boys, 
showing the relative frequency of this rare disease in the two sexes. 

Hematuria. — By hematuria is meant the excretion of urine 
containing blood. This affection is to be distinguished from 
hemoglobinuria, the discharge of blood-coloring matter in the 
urine. In the latter, — a disease caused by the toxemias and found 
especially in scarlet fever, also in measles, typhoid fever, erysipelas, 
and malaria, — the red blood corpuscles are not found by the mi- 
croscope in the urine. 

Blood in the urine is purely symptomatic and may be due to 
local causes, such as stone in the kidney or bladder tuberculosis, 
or tumor of the kidney; or to general causes, such as a hemorrhagic 
diathesis; and most frequent of all, infantile scurvy. The vagina 
as a source of blood must be excluded always by a local examination. 
The presence of blood casts in the urine is a sure sign that the 
blood comes from the kidney and the presence of casts of other 
sorts and renal epithelium points toward the kidney as a source. 
In these cases the blood will be found to be intimately mixed with 
the urine and clots are rare. 

As early as 1889, Gee (St. Barthol. Hosp. Reports, 1889, Vol. 
XXV., p. 85) first called attention to bloody urine as often the only 
sign of infantile scurvy, and more recently J. L. Morse (Journ. 
Amer. Med. Asso., Dec. 17, 1904) has insisted on the importance of 
this symptom in scurvy, reporting seven cases seen by him in the 
course of three years. He considers that hematuria may be the 
earliest symptom of infantile scurvy and therefore, for a time, the 
only symptom, and it is the most common cause of uncomplicated 
hematuria in infancy. J. P. Parkinson (Brit. Med. Journ. of Chil. 
Dis., Feb. 1907, p. 37) has reported a case of infantile scurvy in a 
child eleven and one-half months old, in which hematuria was the 
only obvious sign of the disease until closer examination showed 
other signs. 

There are a few cases on record of hematuria due to the ad- 
ministration of salicylate of soda by the mouth, notably that of 



584 INFANCY AND CHILDHOOD 

Marshall, which appeared in the Lancet for February 2, 1907, 
where a girl of ten had hematuria following the taking of small 
doses of the salicylate. Chlorate of potash, rhubarb, and straw- 
berries have been known to cause hematuria. 



DISEASES OF THE RECTUM 

Attention has been called to imperforate anus and rectum in 
infants in the consideration of the anomalies, page 561. 

Practically all of the diseases of the rectum found in the adult 
are found also in the child since, more particularly in recent years, 
the pediatrists have studied the affections in children. We shall 
mention here only the more common ones. 

Prolapse of the Rectum. — A portion or the whole of the rectum 
may be everted through the anal orifice. The prolapse is said to 
be partial when the mucous membrane alone is extruded, and 
complete when all the coats of the rectum are involved. Rectal 
prolapse occurs slightly more often in girls than in boys. According 
to Bokai's statistics of 360 collected cases, 163 were in male and 
197 in female infants. The affection is most frequent in children 
during the second and third years of life, probably because at this 
time the child is put on the chamber and straining, — particularly 
in those conditions in which straining is excessive, such as dysentery, 
— brings the intra-abdominal pressure more directly on the loosely 
fixed rectum. This is brought about by the lack of curve in the 
sacrum in the infant, thus permitting of more direct abdominal 
pressure from above, and less protection for the rectum from below 
and behind by the cartilaginous coccyx than is the case in the 
adult where the lower rectum is protected by the strongly curved 
bony coccyx. 

Predisposing causes are wasting diseases, such as rickets and 
diseases of the intestine. Enteritis and proctitis, obstinate consti- 
pation, stone in the bladder, and whooping-cough have been known 
to stand in causal relationship to prolapse. 

Prolapse usually occurs during the act of defecation. The 
physician notes a bright red tumor, covered with mucus and 
the size of a walnut, at the anus. It is generally easily reduced, 
but returns with each movement of the bowels, gradually increasing 



DISEASES OF THE RECTUM 585 

in size. Sometimes the application of cold to the prolapse will 
cause it to go back. In the more extensive grades of prolapse the 
tumor may be the size and shape of a small potato — conical in shape, 
with the dimple of the opening of the bowel at its apex, similar to 
the external os in the case of uterine prolapse. The symptoms of 
prolapse besides protrusion are, loss of control over the action 
of the bowels, — shown by the baby's napkins being always soiled, — 
increased frequency of the action of the bowels, and, in cases of a 
severe grade, bleeding of small amount from the prolapsed mucous 
membrane. 

Proctitis. — Inflammation of the rectum occurs in children as a 
part of inflammation of the rest of the large intestine, but may 
occur (rarely) alone. The causes are chiefly local, the most frequent 
being the use of irritating injections or suppositories, either to 
combat constipation or for the administration of drugs. Proctitis 
accompanies thread-worms and is found in cases of gonorrheal 
vulvo-vaginitis from extension of the infection from the vulva, 
either spontaneously or by the introduction of the nurse's or mother's 
finger, or a syringe tube through the anus during the course of this 
disease. Both simple catarrhal and specific proctitis have been 
observed. (See Chapter XXVI., page 506.) 

Fissure in Ano. — This is not very rare in children and is caused 
by the passage of large, hard fecal masses, or by the maladroit use 
of the syringe nozle. The result of the injury of the mucosa of 
the anal canal is an irritable ulcer situated in one of the folds of 
the mucous membrane, pear-shaped or triangular in form, with 
its long axis in the long axis of the anal canal. Pain on defecation 
is the constant symptom. The child cries and resists every effort 
to have the bowels move, so that chronic constipation results. 
The pain may be referred to other parts in the neighborhood. 
The ulcer is felt by the well-anointed finger passed into the anus 
as a rough spot and it is seen by introducing a large Kelly cysto- 
scope (No. 12) through the sphincter and inspecting the surface of 
the mucous membrane as it rolls into the lumen of the cystoscope 
as the instrument is withdrawn. 

Incontinence of Feces. — Incontinence of feces is a symptom of 
prolapse of the rectum. It is seen in cases similar to incontinence 
of urine in children who are over three years of age, and may be 
associated with the latter affection. Fowler (Amer. Journ. Obstet., 



586 INFANCY AND CHILDHOOD 

1882, XV., p. 984) mentions the case of a girl of thirteen years in 
whom incontinence of feces had persisted from infancy. In this 
case the sphincter ani was decidedly relaxed. A. Riviere (Medi- 
cine moderne, 1898, Vol. IX., p. 308) reports the case of a girl of 
twelve years, where incontinence, beginning at nine years, was due 
to chronic overdistention of the rectum. The rectum in this case 
was found to be greatly distended. 

The cause of this affection is generally clearly an affair of the 
nervous system, just as in the case of enuresis. According to the 
reported cases it occurs more frequently in boys than in girls. 

Incontinence of feces is found in cases of chronic wasting diseases, 
epilepsy, myelitis, and in injury to the lumbar portion of the spinal 
cord ; also in meningitis, and occasionally in typhoid fever. In all 
cases not of manifest central nervous origin the sphincter ani 
should be examined as to its tonicity, and also a proctoscopic ex- 
amination of the rectum should be made to detect overdistention 
and relaxation of that organ. 



CHAPTER XXIX 

THE MENOPAUSE AND OLD AGE 

The menopause, p. 587: General considerations, p. 588. Anatomical 
and physiological considerations, p. 592; Anatomy, p. 592. Atrophic 
changes in the uterine organs, p. 594; Physiology, p. 595. Age at which 
the menopause occurs, p. 597. Premature menopause, p. 598. Delayed 
menopause, p. 601. The dodging time, p. 611. Phenomena of the meno- 
pause in body and mind, p. 612; Cardio-vascular system, p. 612, Hot 
flashes, p. 612, Tachycardia and high arterial tension, p. 613; The nervous 
system, p. 613; Sexual feelings, p. 614; Mental diseases, p. 615; The 
alimentary canal, p. 615; The nutrition, p. 616; Rheumatism, p. 616; The 
skin, p. 617. Influence of uterine diseases on the menopause, p. 617; 
Hemorrhages, p. 617; (a) Fibroids, p. 617; (6) Subinvolution, p. 618; 
(c) Endometritis, p. 618; (d) Polypi, p. 618; (e) Cancer of the uterus, p. 
619; Displacements of the uterus, p. 620; Cystocele and rectocele, p. 621; 
Vaginitis and injuries of the vagina from coitus, p. 621 ; Eczema or pruritus 
vulvae, p. 621; Vesical symptoms, p. 621. 

Old age, p. 622: General considerations, p. 622: Effects of old age on 
the ovaries, p. 623; On the Fallopian tubes, p. 623; On the uterus, p. 624; 
On the vagina, p. 625; On the vulva, p. 625. 

The menopause (vyves , menses, and Trader, cessation) sometimes 
called the change of life, or climacteric, the time when the cata- 
menia cease, marks not only the end of the reproductive period 
in the life of woman, but it means also a change in the psychical as 
well as in the bodily make-up of the individual. It occurs in tem- 
perate climates after a period of from thirty to thirty-two years of 
menstrual life, between the ages of forty-five and fifty years. Then 
ensues a period of rejuvenescence of ten or fifteen years in which 
the woman, freed from the annoyances and disturbing influences at- 
tendant on menstruation and childbearing, settles into a more staid 
and less emotional form of life, when she devotes herself to the duties 
and problems that confront her without the demands on her strength 
that reproduction or preparation for reproduction entail. 

As regards old age it becomes necessary at the outset to dis- 
tinguish between the general application of the term to the latter 
part of life and that portion of it in which there are present distinct 
evidences of degeneration of body or mind. Perhaps the latter 
time is more accurately defined by the term senility. That some 
individuals maintain vigor of both body and mind even to ad- 
vanced years, is common observation, so that placing a mark in 

587 



588 THE MENOPAUSE AND OLD AGE 

number of years for the beginning of senility is a manifestly difficult 
proceeding. The ancients said, — "iEtas non annis sed viribus 
Eestimatur." Nevertheless, Hippocrates placed the beginning of 
senility at fifty-six years; Daubenton, who lived in the eighteenth 
century, at sixty-three, and Flourens ("De la longevite," 1854), 
some hundred years later, at seventy. Most authors adopt a con- 
ventional age of sixty as the beginning of the retrogressive changes 
of old age, and we will follow their lead. 



THE MENOPAUSE 

General Considerations 

The term menopause, although signifying only the cessation of 
the menses, is, on the whole, the best we have to describe a com- 
plex condition. Whether the catamenia cease suddenly or by 
irregularly recurring periods scattered over a number of months 
or years, the stopping of the menses is only one symptom attend- 
ing changes not only in the reproductive organs, but also in many 
other organs and in the system at large, these changes having 
their origin in a cessation of the function of the ovaries. The 
symptoms consist roughly of the following: — On the part of the 
uterus, hemorrhages and leucorrhea; the heart, palpitation and 
irregular rhythm; the arteries, increased tension and hot flashes; the 
nervous system, neuralgias, insomnia, depression of spirits, and ner- 
vous instability; the alimentary tract, dyspepsia, gastro-enteritis, 
and constipation; the kidneys, renal insufficiency; the skin, derma- 
toses; and the general nutrition, obesity, rheumatism, and anemia. 

Among the savages, who lead an out-of-door life and are the least 
removed in their mode of existence from the animals, it would 
appear that the menopause occurs without any symptoms except 
the cessation of menstruation. (A. Currier, Amer. Gyn. Trans., 
Vol. 16, 1891.) Among the civilized races, however, the more 
artificial the life the more likely the occurrence of one or more of 
the symptoms enumerated. In fact, the absence of symptoms 
dining the change of life may be regarded as abnormal among 
women of all classes and conditions of life in civilized communities 
to-day. This should not be construed as meaning that the meno- 
pause is a critical time of life or that the gloomy views about this 



THE MENOPAUSE 589 

period that obtained in ancient times, or even thirty or forty years 

ago, should be held true at the present time. For instance, Kisch 

("Das klimakterische Alter der Frauen," 1874, p. 109), writing in 

1874, gives the following table of gynecological affections he found 

in 440 women who complained of symptoms referable to the uterine 

organs, among five hundred women investigated, in many cases 

several diseases being found in one individual: — 

Cases 

Menorrhagia and metrorrhagia in 286 

Chronic metritis 79 

Leucorrhea 327 

Prolapsus uteri 65 

Ante- and retroflexion of uterus 52 

Pruritus vaginae 46 

Vaginismus 12 

Carcinoma uteri 3 

Uterine polyp 5 

Tumor of the breast 8 

Tilt ("The Change of Life/' E. J. Tilt, 1882, p. 143) has an 
even longer list of uterine diseases found in five hundred women, 
as follows: — 

Cases 

Floodings, in 138 

Leucorrhcea 158 

Remittent menstruation 33 

Vaginitis 4 

Follicular inflammation of the vulva 10 

Inflammation of the labia 4 

Ulceration of the neck of the womb 9 

Hypertrophy and inflammation of the womb 2 

Prolapsus of the womb 5 

Uterine polypi 4 

Uterine fibrous tumors 4 

Uterine cancer 4 

Ovarian tumors 3 

Milky or glutinos secretion of the breasts 2 

Irritation and swelling of the breasts 14 

Tumor of the breast, non-malignant 2 

Cancer of the breast 1 

Habitual deposits in the urine 49 

Pain and difficulty in passing urine 9 

Incontinence of urine 4 

Haematuria 1 

Erectile tumor of the meatus urinarius 2 

Perineal abscess 2 

464 



590 THE MENOPAUSE AND OLD AGE 

The earlier writers believed that many maladies of serious 
nature were necessarily due to the menopause and this view is 
still held by many, not only of the general public, but by members 
of the medical profession. The reason is to be found in the absence 
of accurate diagnosis in the past. For instance, take the uterine 
disease, fibroid tumor of the uterus. We know now that these 
tumors are the cause of a very large number of cases of flowing at 
the menopause, and further that, unless there is surgical interference, 
the cessation of the menses in these cases does not come for several 
years after the time observed in women who have no uterine disease. 
Fibroid cases were formerly included in the statistics of the meno- 
pause, whereas now they are treated surgically so often and are 
generally recognized as fit subjects for operative treatment, that no 
one thinks of leaving them to the kind offices of nature unassisted. 
The early recognition of uterine cancer was an unknown branch of 
diagnosis fifty years ago and instances of flowing caused by this 
dread disease were classed as natural concomitants of the climacteric. 
Now we know that cancer is found most frequently in both sexes 
between the ages of forty-five and fifty-five and there is reason to 
believe that the disease has some association with retrogressive 
changes in the tissues. 

At all events this holds true in the case of cancer of the breast 
where the atrophy of the tissues of the breast at the menopause 
is associated with the development of cancer in that organ. It is 
more than probable that the same may hold true of the uterus. 
Fibroids and cancer of the uterus are, therefore, truly diseases of 
the menopause, although the causative relations of the climacteric 
to these diseases is by no means proved, consequently they should 
be always in the mind of the practitioner while considering the 
case of a woman who is passing through this period of life. The 
point to keep in mind in this connection is that it is the uterine 
disease that causes the patient's ill health and not the time of life 
during which the disease manifests itself, in the same measure 
as regards the constitutional diseases. Tilt mentions in his table 
forty-nine cases of " habitual deposits in the urine." Now we 
look for faults in metabolism and a diminished ingestion of fluids 
to explain such deposits. 

In a study of the menopause for the purpose of gaining an in- 
sight into its true nature, one considers first the physiology of the 



THE MENOPAUSE 591 

change of life in a normal woman and then the points of departure 
from the normal. If such a thing were possible we should utilize 
statistics of the symptoms manifested by women having normal 
uterine organs when they are passing through the period of the 
change. Most of the figures given by writers on this subject, such 
as Brierre de Boismont, Kisch, Kehrer, Tilt, and Borner, are made 
up largely of women suffering with uterine diseases. Normal 
women do not apply to physicians for advice, and whatever symp- 
toms they experience are not a matter of record, or are not sub- 
jected to expert analysis; therefore, most of our ideas must come 
from study of abnormal women and chiefly from those who are 
affected with uterine disease. The many variations in general 
health exhibited by women who are undergoing the menopause 
complicate an investigation into the phenomena and therefore 
hinder the sifting of cause and effect. 

During the last twenty years, since abdominal operations on the 
uterine organs have become so common, frequent opportunities 
have presented for more accurate study of the condition of these 
organs during and subsequent to the menopause. Moreover, our 
knowledge of the artificial menopause, induced by the removal of 
the ovaries, has become very minute of late years, because of the 
unfortunate practice which obtained in the eighties and nineties of 
removing the ovaries for the cure of a variety of diseases of the 
nervous system, and also, since the era of aseptic abdominal oper- 
ating began, the frequent sprayings made necessary by ovarian 
disease have furnished many examples. 

In this chapter I shall approach the subject of the menopause 
from the standpoint of the gynecologist, citing first the opinions 
of the most eminent authorities and then my own views formed by 
reading the literature and by an analysis of one hundred and fifteen 
cases taken from my private case records of women who were 
between the ages of forty-one and fifty-nine years, who had either 
passed by the menopause or were passing through it, all of the cases 
being women who consulted me for uterine disease. No cases of 
myoma or cancer are included except a few cases of small uterine 
polypi which may have been of myomatous origin, and a few cases 
of cancer of the uterus which were several years past the meno- 
pause. 



592 THE MENOPAUSE AND OLD AGE 

Anatomical and Physiological Considerations 

Anatomy. — The ovaries are developed in the embryo from epi- 
blast and mesoblast on the inner surface of the Wolffian bodies in 
close relationship with Miiller's ducts, which eventually form the 
Fallopian tubes, uterus, and vagina. Most of the ovary is composed 
of cortex, which is made up of primary ova enclosed in primary 
follicles which lie in a delicate connective-tissue framework. At 
birth there are some one hundred thousand of these primary ova 
present in an ovary, over half of them disappearing before puberty 
is reached, and the rest developing into ripened ova in their Graafian 
follicles to be constantly diminished in number during the thirty or 
thirty-two years of sexual maturity by the repeated discharge of 
ova through the surface of the ovary, leaving it, as the years go 
by, with an ever-increasingly corrugated appearance. 

After the ovum has escaped from the Graafian follicle there is 
formed, on the inner surface of the walls of the follicle, the corpus 
luteum, a wrinkled yellow membrane made up of polygonal epithe- 
lioid lutein cells, the yellow color being due to the lutein. If preg- 
nancy supervenes the corpus luteum persists for a long time; if it 
does not, connective tissue takes the place of the lutein cells, the 
yellow color disappears, and the corpus is gradually absorbed. 

When the menopause has been established the cortical zone of 
the ovary is diminished in thickness, the ova and their follicles 
disappear, and the ovary becomes progressively smaller in size 
and more shrunken in appearance as the connective tissue, of 
which it is now mainly composed, atrophies with the advancing 
years. 

The office of the ovary is to furnish ova, and in addition it has 
an important influence on various functions of the body, chiefly 
the circulation of the blood, the nervous system, and the nutrition. 
The theory has been suggested by various observers that the 
ovaries are ductless glands like the thyroid and suprarenal glands 
and that they furnish an internal secretion. More recently the 
view has gained ground that this internal secretion is produced by 
the corpus luteum. This is not the place to discuss the various 
theories and the facts advanced to substantiate them. Suffice it 
to say that as yet we know nothing more than probabilities and these 
seem to me to be that the ovaries exercise their influence on the 



THE MENOPAUSE 593 

system chiefly through the circulation, an argument in favor of 
the theory of an internal secretion. 

The function of the thyroid gland seems to have some relation to 
that of the ovary, both being in sympathy as essential to the develop- 
ment and preservation of the genital organs, and yet opposed in 
certain respects, as shown by the enlargement of the thyroid at 
the menopause. Thyroid feeding produces excellent results in 
cretinism and in infantilism, and ovarian extract ameliorates the 
symptoms of exophthalmic goitre. Vinay ("La menopause," 1908, 
p. 60) points out that in parts of Switzerland where goiters are 
common, many women develop these tumors for the first time at the 
menopause, but not before or after. The suprarenal glands have 
been found hypertrophied, or the seat of tumor formation, in cases 
of sexual precocity; and atrophy has been found associated with 
insufficient development of the genital organs, so we are led to be- 
lieve that these organs have an intimate relationship with the 
ovaries. 

Hegar likened the tubes, uterus, and vagina to the duct of a gland, 
the ovary. Disappearance of this gland results, as in similar 
processes in other glands, in disappearance of the duct also. So in 
the developmental stage of the organism the growth of the duct is 
related to that of the gland, and when in anomalies the ovaries are 
found absent, the tubes and uterus or the vagina are generally 
either defective or wanting. At the time of the menopause the 
atrophy of the ovary is accompanied not only by a cessation of 
menstruation, but by a shrinking of the tubes, uterus, vagina, and 
external genitals, all a slow process requiring a variable amount of 
time in different individuals, but always, in all probability, a series 
of months or years. 

In the following case reported by J. C. Dalton {Trans. Amer. 
Gyn. Soc, 1878, Vol. 2, p. 134), the ovaries one year after the 
menopause showed Graafian follicles in a state of degeneration, 
and no corpora lutea: — U A woman, forty-three years of age, of 
average bodily development, who had had one child twenty-one 
years before, died at the Charity Hospital, New York, February 7, 
1877, of cerebral meningitis. Menstruation had ceased within a 
few days of one year before death. 

"The uterus was empty, of medium size, and normal in appearance 
except for a constriction of the os internum, which was reduced to 
38 



594 THE MENOPAUSE AND OLD AGE 

an orifice two millimeters in diameter.. The uterine mucous mem- 
brane was generally smooth and pale, marked only with a slight 
arborization of fine blood-vessels. The ovaries were somewhat 
undersized, and loose in texture. They contained a number of 
collapsed, empty, degenerate Graafian follicles with slightly thick- 
ened walls, presenting the appearance of having been long in an 
inactive condition. One ovary contained ten or fifteen such bodies, 
the other from fifteen to twenty. In the ovarian tissue there were 
also a few small, blackish stains, without definite structure. There 
were no normal Graafian follicles anywhere, and no corpora lutea 
in either organ." 

In contrast to this case Puech (cited by E. Borner, "Die Wech- 
seljahre der Frau," 1886, p. 8) found the ovaries of normal size in a 
woman three years after the menopause. In my own list of cases 
(Case No. 17, see table on page 605) I removed atrophic ovaries 
from a single woman forty-one years of age before the menopause 
had become established, although the patient had been in the 
dodging time for two years; whereas in Case 60, that of a married 
woman of forty-six, the ovaries were normal in size and appear- 
ance at operation one year after the beginning of irregularity of 
the menses. As a rule I have found the ovaries atrophied at opera- 
tions performed on patients who have passed the menopause (as in 
Case 108) except in cases where the ovaries with their tubes were 
the seat of a chronic inflammatory process. 

Atrophic Changes in the Uterine Organs. — During and following 
the cessation of menstruation retrograde metamorphosis takes 
place in the ovaries, the Fallopian tubes, the uterus, the vagina, 
and the external genitals, the process of atrophy of these organs 
requiring a variable amount of time in different individuals and 
proceeding with the same rate of speed in the different organs in no 
two patients alike. In the absence of definite demonstrable patho- 
logical conditions the atrophic changes should proceed from the 
ovaries downward, involving in progressive sequence tubes, uterus, 
vagina, and external genitals, and this, I think, is the rule. The 
tubes lose their lining epithelium and finally their lumen is closed 
and they become mere cords; the uterus becomes smaller in all its 
dimensions, its walls grow thinner, and the internal os is contracted 
and is often obliterated. The cervix generally atrophies before 
the body of the uterus, becoming shorter and thinner, but in women 



THE MENOPAUSE 595 

who have regular sexual intercourse this may not be the case, and 
of course, if the cervix is the seat of old lacerations and chronic 
metritis, it may be the last portion of the organ to show atrophic 
changes. 

When the menopause is well established the vagina, which 
during the change is apt to be hyperemic, becomes pale, — perhaps 
only in patches, while the rest is dark red; it is narrower and 
shorter and assumes a conical shape because the contraction is 
greatest in the upper portion. It loses its elasticity and the mucous 
membrane gradually is deprived of its rugse, so that the walls 
become more friable and the surface smoother. Sometimes coitus 
in the case of an atrophic vagina causes excoriation, pain, and 
bleeding, and may be the source of impairment of the nervous 
balance of the patient. Laxity of the tissues of the vagina with 
atrophy of the muscular walls at the menopause favors. prolapse. 

The changes in the external genitals consist in loss of subcutaneous 
fat and in a gradual shrinking, but these transformations are so 
closely bound up with the nutrition of the system as a whole, that, 
although having their origin at the menopause, they are generally 
not marked until old age. Therefore, we seldom note absence of 
fat under the mons veneris and the labia pudendi until old age sets 
in, even in the cases of premature and artificially induced menopause. 
The condition here is not dissimilar to that in the mammas which 
atrophy at the menopause, the gland tissue being replaced by 
fatty tissue, which is deposited in abundance throughout the 
entire body, especially in its upper portions, at this time. 

Physiology. — To obtain an understanding of the physiology of 
menstruation it seems to me that the menstrual-wave theory 
developed by Mary Putnam Jacobi ("On the Question of Rest for 
Women during Menstruation," 1878) and by William Stephenson 
(Amer. Journ. Obstet., 1882, Vol. XV, p. 287) offers the best 
explanation. It is that menstrual life is associated with a well- 
marked wave of vital energy manifested by variations in the body 
temperature, in the daily amount of excretion of urea, and in the 
arterial tension, as demonstrated by the investigations of these 
authors. The highest body temperature, the greatest daily ex- 
cretion of urea, and the highest arterial tension as registered by 
the sphygmograph occur at a period of five or six days before 
menstruation, and the lowest point of all three of these indices of 



596 THE MENOPAUSE AND OLD AGE 

the vital processes is just after the cessation of menstruation. In 
other words, the woman's system is prepared by a gradual rhythmic 
process for menstruation and reproduction. We know that at the 
menstrual period the uterus, ovaries, tubes, and vagina pass through 
a phase of increased functional activity and engorgement that 
necessitates an increased blood supply to these organs. Accordingly 
the tributary arteries dilate and the arteries of the rest of the body, in 
obedience to the law of compensation, undergo a vaso-constriction, 
whence the slight drop in arterial tension noted by Stephenson in 
the radial pulse just before and during menstruation. The blood 
in the pelvic circulation is forced at increased pressure through 
the capillaries of the uterus, with a result that there is hemorrhage 
from the endometrium. 

It is plain that anything that profoundly upsets the balance of 
blood-pressure upon which menstruation depends may cause 
either an increase in the flow or a diminution, or even cessation. 
This upsetting may come through the nervous system, as in the 
case of nervous worry or shock, or it may come directly through 
the circulation. Dr. Francis Hare (Clinical J own. , Aug. 29, 1906) 
has reported a case where the inhalation of amyl nitrite immediately 
checked a normal menstrual flow, and in the olden days when our 
forefathers employed venesection as a universal therapeutic measure 
it is reported that blood-letting, in the case of a menstruating woman, 
was followed by the same result. In one case the blood was re- 
moved from the pelvis by vaso-dilation of the systemic arteries, 
and in the other by abstraction from the general circulation. The 
tonicity of the blood-vessels, of the portal system, that great reser- 
voir of the body, must have an important influence on menstruation, 
and in the future we may look to see results of investigations on 
the circulation conducted to determine the causes of greater or 
less congestion of the uterine organs at the catamenia. 

We may regard the time between menstrual periods not as a 
period of rest from preparation for reproduction, but as a marshal- 
ing of the forces which reach their acme just before the molimen, 
then, after a brief period of slack water, to rise again to high tide, 
with ever-recurring regularity of rhythm until the stimulus ceases 
to emanate from the ovary and menstruation and the capacity for 
reproduction are no more. 



THE MENOPAUSE 597 

Age at which the Menopause Occurs 

All the statistics found in the literature as to the age of the 
beginning of the menopause are unsatisfactory because they in- 
clude chiefly women having all sorts of uterine diseases as well as 
those afflicted with various other bodily ailments. Many of the 
statistics include the cases of premature menopause. For these 
reasons the available statistics do not represent fairly the average 
age of the occurrence of the menopause, at least among women 
who are not the subjects of uterine disease, for it is my belief that 
uterine disease is the principal cause of prolongation of the men- 
strual function. As long ago as 1869 E. Krieger ("Die Menstru- 
ation," p. 171) gathered the statistics of six authors, of which the 
following is a summary: — 

Two thousand two hundred and ninety-one cases reported by 
Mayer, Tilt, Guy, Brierre de Boismont, Courty, and Puech. 

Between the No. of Percentage 

years cases of all 

36-40 '. 272 11.87 

41-45 595 25.97 

46-50 940 41.03 

51-55 334 14.58 

Before 35 

or after 55 150 6.54 

In this list the greatest number of cases were the women who 

ceased to menstruate between the ages of forty-six and fifty. Tilt 

(loc. cit., p. 26) gives an average age of 45.7 among 1,082 women 

observed in London and Paris, including the cases of premature 

menopause. 

As regards the influence of race or locality on the time of the 
menopause we know so little from what sort of women the statistics 
were gathered, and the figures of different observers are so much at 
variance, that the only conclusion we are justified in drawing is 
that the age is somewhat more advanced in the women of the 
higher latitudes than is the case in those living nearer the equator; 
and in the Jewish race the menopause occurs relatively early in 
whatever part of the world the women happen to live. As an ex- 
ample of the variability of statistics concerning neighboring races 
leading a similar mode of life, we may cite the following: — 

In a study of the menopause among the American Indians 



598 THE MENOPAUSE AND OLD AGE 

Andrew F. Currier (Trans. Amer. Gyn. Soc, 1891, Vol. 16, p. 274) 
found an average age of 47.2 among twenty-five Sioux Indians, 
and 53.4 among ten of the Cheyenne and Arapahoe tribes. He states 
(loc. cit., p. 277) that among the Quapaws the child-bearing period 
ends at thirty-five to forty, whereas among the Crows and Assini- 
boines (loc. cit, p. 278) the child-bearing period frequently con- 
tinues until the forty-fifth year. Tilt gives a table of the compara- 
tive dates of the cessation of menstruation in different countries 
as follows: — France, Paris, 44, Rouen, 48.7; England, 46.1 and 
47.5; Central Germany, 47; Denmark, 44.8; Norway, 48.9; Lap- 
land, 49.4; Russia, 45.9. 

Something must be assigned to the influence of heredity in the 
matter of the age at which the menopause is established. It has 
been my observation that the climacteric appears at about the same 
age in mother and daughter; that a late or an early menopause 
is a common characteristic in the women of certain families. My 
personal experience as to the average age has to do with an analysis 
of the records of eighty-eight cases of women between the ages of 
forty-one and fifty-nine who consulted me in Boston or New 
England, for uterine disease. (See tables, pp. 604-611). All cases 
of myoma, cancer of the uterus which manifested itself previous 
to several years after the cessation of the menses, and, of course, 
artificially induced menopause, are excluded. The average age 
of the menopause in these cases was 46.78 years. This may be 
considered as a fair average for women with uterine disease ex- 
clusive of fibroids and cancer, who live in New England, although a 
larger number of cases, both of those afflicted with gynecological 
troubles and of more nearly normal women, should be gathered 
and analyzed before arriving at definite conclusions. 

Premature Menopause 

The cessation of the menses previous to the normal average time 
is known as premature menopause, but as variations from the 
normal an 4 so frequently seen it will be convenient to consider as 
cases of this abnormality those which occur before the fortieth 
year. The important point to bear in mind in establishing the 
diagnosis is to be sure that a reasonable time has elapsed since 
the last menstrual period to make its recurrence in the future 



THE MENOPAUSE 599 

seem improbable. Apprehensive patients often think the change 
of life is at hand upon the occurrence of a transitory irregularity 
in the menses. 

A direct cause for the cessation of the menses early is to be found 
sometimes in (a) a sudden blow or fall, extreme fright, anxiety, or 
grief acting through the nervous system; (6) serious constitutional 
diseases, such as cholera, septicemia, the acute exanthemata, or 
poisoning by alcohol, phosphorus, mercury, arsenic, or lead; (c) 
diseases affecting the uterine organs directly, such as excessive 
lactation-atrophy of the uterus, steaming of the uterine cavity 
after the method of Pincus (see p. 286), or inflammations and 
tumors of the ovaries. Other factors which seem to stand in a 
causal relationship to an early menopause are rapidly succeeding 
pregnancies beginning early in life, and excessive venery. Some 
authors consider that the southern races who mature relatively 
young have the menopause correspondingly early; but others do 
not agree to this view and consider that there is no relationship 
between the age at which menstruation begins and the time of its 
cessation. Obesity, especially that form which is rapidly acquired, 
is a cause of an early menopause both in the opinion of A. Currier 
(Medical News, 1888, p. 173) and myself. 

Although any of these causes may result in a permanent disap- 
pearance of the menstrual flow, we are by no means sure, as pointed 
out by Borner (loc. cit.), that ovulation is also abolished and that 
true cessation of the reproductive function has been established, 
and we may agree with him in the statement that many of the 
reported cases of premature menopause are to be regarded with 
suspicion because the absence of the menses for a sufficiently long 
period of time has not been observed and because an accurate 
gynecological examination eliminating the common causes of 
amenorrhea has not been made. 

How causes in class (a) act to produce amenorrhea we do not 
know. It is probable that the general constitutional diseases act 
directly on the ovaries. We know that the exanthemata cause 
changes in the ovaries, as shown by Lebedinsky's examinations of 
the ovaries from cases of scarlet fever. (See Chapter XVII., p. 285.) 
C. Vinay ("La menopause," 1908) has called attention to the 
frequency with which sclerosis of the ovaries is found in tuberculous 
individuals, and Slavjansky, according to Borner, found paren- 



600 THE MENOPAUSE AND OLD AGE 

chymatous inflammation of the ovary in cholera, recurrent fever, 
and septicemia. 

The destructive diseases of the ovaries originating either in those 
organs or in the neighboring organs of the pelvis, may well cause 
the menopause. The surprising fact is that they so seldom do 
cause it, for in cases of large cystomata of both ovaries where at 
operation no sound ovarian tissue can be discovered by macro- 
scopic examination, the patients generally report that menstruation 
has taken place with more or less regularity during the growth of 
the tumors. We must assume in such cases that some function- 
ating ovarian tissue has been preserved, even though it can not be 
easily discovered. We know that in ovarian transplantation from 
one individual to another, menstruation and ovulation continue 
as long as ovarian tissue is present, even though this tissue is not 
in its usual situation with reference to the uterus, and it seldom 
happens that destructive inflammatory processes completely 
eliminate all of both ovaries. 

A recent writer (M. M. Stark, Surg., Gynecol., and Obstet., Jan., 
1910, Vol. X., p. 40) has collected from the literature the following 
fifty-nine cases of premature menopause, occurring between the 
ages of seventeen and thirty, all reported by reliable authorities. 

Menopause at Reporter No. of Cases 

17 Iiisch 1 

18 Stark 1 

19 Frazer, Stark, 1 each 1 

20 Dalton, Kisch, Stark, 1 each 3 

21 Schalit 1, Boismont 2, Courty 1, Stark 1 5 

22 Mayer 2, Stark 1 3 

23 Krieger, Walter, Stark, 1 each 3 

24 Boismont, Stark, 1 each 2 

25 Mayer 2 

26 Montgomery 1, Munde 1, Boismont 1, Stark 2 5 

27 Tilt, Guy, Boismont, 1 each 3 

28 Foster, Currier, Guy, Boismont, Stark, Courty, 1 each . 6 

29 Mayer, Boismont, Courty, Napier, 1 each 4 

30 Mayer 5, Tilt 10, Guy 1, Felty 1, Napier 1, Stark 1. . . 19 

The number of cases occurring between thirty and forty years 
of age is, of course, the largest. Bonier (loc. tit., p. 39) gives the 
following as a genuine case of premature menopause of unknown 
causal ion: "Mrs. H., now thirty-nine years old, menstruated 



THE MENOPAUSE 601 

regularly after twelve years of age. Married at thirty-four and 
aborted twice in the course of two years. When she was thirty-six 
her husband, who had been seriously ill and for whom she had 
cared constantly, died suddenly. Her menses ceased on the second 
day of her period and although she saw slight traces of a flow 
twice subsequently at intervals of four or five months, there had 
been absolutely no flow for the past two years. The only symptom 
was mental depression. On local examination the vagina was 
somewhat shortened and contracted; the cervix thin- walled, soft 
and small, with a tear (one of the abortions was a rapid one at 
six months), and the uterus as a whole very thin- walled and almost 
membranous. The ovaries, of practically normal consistency, were 
freely movable but small in size." 

Delayed Menopause 

The menopause may be said to be delayed when menstruation 
is continued beyond the fiftieth year. 

An important point in diagnosing this condition is to distinguish 
between irregular hemorrhages and menstruation. In many cases 
careful questioning of the patient is necessary to bring out the 
difference clearly. 

Are ovulation and fertility- prolonged with menstruation? There 
are many cases on record of both menstruation and childbearing 
late in life, some of them most sensational and far too large a pro- 
portion founded on hearsay evidence rather than on the personal 
observation of the reporters. One of the earliest cases is that 
recorded by Pliny the Elder, of Cornelia, of the family of Scipio, 
who at the age of sixty bore a son who was named Volusius Satur- 
ninus. Fordyce Barker ("The Age of Women When the Capacity 
for Childbearing Ceases," Phila. Med. Times, 1874) pointed out 
that the eldest child of Cornelia was born in the year 163 B.C. and 
that Pliny was born in the year 23 a.d. and his " Historia Natur- 
alis" was published about the year 77; therefore, at least two 
hundred years must have elapsed from the time of this extraor- 
dinary birth to the time when Pliny wrote. Pliny gave no docu- 
mentary evidence and, as he was something of a romancer at best, 
we may class the case as a tradition and not as an observed fact. 
In the same way, if the cases in the literature are examined carefully 



602 THE MENOPAUSE AND OLD AGE 

and the sources of information sifted, the facts generally rest on 
hearsay evidence. Take the case of Ann Woods who is said by Dr. 
Benjamin Rush "to have given birth to a child after she was 
sixty years old." In this case the evidence of the truth of the story 
rests entirely upon the assertion of the old woman herself who 
claimed to be ninety-six years of age when she called at Dr. Rush's 
home "to beg for cold victuals." 

Dr. Fordyce Barker (loc. cit.) reports the following authentic 
case of late childbearing: "May 6, 1852, I attended a case of labor 
in St. Mark's Place, New York City, in consultation with the late 
Dr. Robson, of this city. The labor was normal but tedious and 
our patient was delivered of a daughter by the aid of forceps. This 
lady had been married twenty-seven years and this was her first 
pregnancy. After the birth of the child, the husband showed to 
Dr. Robson and myself a family Bible, in which the birth of his 
wife was recorded as having been May 5, 1801. July 3, 1853, 
Dr. Robson having died, I attended this lady in her second con- 
finement. The mother and both daughters (now married) are still 
living." 

John Davies (Lond. Med. Gazette, 1847, Vol. 39, p. 950) reported 
the case of a woman proved to be sixty-three years old by her 
baptismal certificate, who had a child when fifty-five years old. 
The child, a girl eight years old, the youngest of eleven children, 
was brought to see Dr. Davies. The mother had not menstruated 
since the birth of her youngest child and she thought that men- 
struation had begun early, when she was twelve or thirteen years 
old. 

More remarkable still is a case reported by W. J. Kennedy 
(Trans. Edinburgh Obstet. Soc, 1881-82, Vol. VII., p. 77) of regular 
menstruation and a child born at sixty-two, to a thrice-married 
woman, the mother of twenty-one children. The facts in the case 
are well authenticated, Dr. Kennedy having known the woman 
for ten years and attended her in her last labor, in November, 1880. 
I ler husband, when applying to the parochial board for relief in 1879, 
stated that his wife was then sixty years old. She was borii in 
October, 1818, and was first married in 1838, her husband dying after 
one child was born. By her second husband she had nine children, 
(wins once, and two miscarriages, and by her third husband eleven 
children and one miscarriage. Her great fecundity outlasting the 



THE MENOPAUSE 603 

normal limit and the regularity of childbearing are attested by 
the following table of the years when the last pregnancies oc- 
curred : — 

Year Age of Patient 

1865 47 

1867 49" 

1869 51 

1871 53 

1874 56 

1878 60 miscarriage 

1880 62 

Apparently ovulation continues sometimes after menstruation 
has ceased, as attested by the following cases. Taylor ("Medical 
Jurisprudence/' p. 736) reports the following: "A woman at forty- 
four had given birth to nine children. Then the menses were 
scanty at the regular periods for two years. They then ceased 
entirely for a year and a half and at the end of that time 
she , w T as delivered of her tenth child. Therefore, conception 
must have taken place eight or nine months after the cessation 
of the menses." 

R. G. Hann (Journ. Obstet. and Gyn. of Brit. Empire, 1902 ; 
Vol. II., p. 290) reports the case of a woman who in her forty-ninth 
year gave birth to her thirteenth child after a period of amenorrhea 
of three years following the birth of the twelfth child at forty-six. 
That ovulation may take place without menstruation the patho- 
logical finding of De Sinety (Progres medical, 1877, No. 23, p. 450) 
goes to show. He described the post-mortem appearances in a 
woman thirty-eight years of age who had never menstruated. The 
uterus consisted principally of cervix, as in the fetus, and the uterine 
cavity measured one and a half to two inches in length. The 
ovaries contained numerous corpora lutea. 

I think we may assume that menstruation as well as ovulation 
occasionally lasts as late as sixty years. Kisch (loc. cit., p. 27) 
cites a case of Brierre de Boismont as follows: — The woman men- 
struated first at twelve, was married, had several children, and 
continued to menstruate without interruption until sixty, after 
which she had an irrregular show for four or five months. Raci- 
borski (idem) observed in the Salpetriere one woman who men- 
struated at fifty-seven, one at fifty-six, one at fifty-three, and two 



604 



THE MENOPAUSE AND OLD AGE 



at fifty-two. Tilt (loc. cit., p. 26) gives the following list of his 
cases of over fifty years of age, including fibroids, cancer, and all 
diseases presumably: — 



Age 
51.. 
52.. 
53.. 
54.. 
55.. 
56.. 



No. of Cases 

27 

16 



Age 
57. 
58. 
59. 
60. 
61. 



No. of Cases 
2 



In my own list of cases, from which fibroids were excluded, the 
menopause occurred at over fifty years as follows: — 



Age 
51.. 
52.. 
53.. 



No. of Cases 

5 

2 

1 



Age 
54.. 
55.. 



No. of Cases 

2 

2 



As before stated, it has been my observation that fibroid tumors 
cause a delay in the menopause. Often in these cases irregular 
hemorrhages take the place of menstruation and a most pains- 
taking inquiry into the symptomatology is necessary to distin- 
guish menstruation from hemorrhage. 

LIST OF WOMEN BETWEEN THE AGES OF 41 AND 59 WHO WERE 
PASSING THROUGH OR HAD RECENTLY PASSED THE MENOPAUSE. 



6 


o5 

a 


6 






> w CD 




O bO 

.fi.5 CD 

+3 m q 
--a 


Leading symptoms and 


fe 


& 


< 


Kg 




cd ° £ 
<! 


CD £ CD 


diagnosis. 


1. 


A. B. 


43 


Mar. 


6ch. 

youngest 

8 yrs. 




42J 


6mos. 


Tachycardia, pruritus vul- 
vae, ovaries atrophied. 


2. 


J. B. 


42 


Mar. 


lch. 

17 yrs. 


42 


40 


2 yrs. 


Flowing, feeling of suffo- 
cation, uterine polyp, 
tubo-ovaritis. 


3. 


S. B. 


43 


Mar. 


lch. 
22 yrs. 


43 


42 


1 yr. 


Headaches, lacerated cer- 
vix and perineum, ret- 
roversion, uterus atro- 
phic. 


4. 


R.K.B. 


58 


Mar. 


No. ch. 
No. ab. 


55 


46 


9 yrs. 


Dyspepsia, tubo-ovarian 
abscess, under observa- 
tion eleven years. 


5. 


E.J.C. 


55 


Mar. 


lch. 




52 


3 yrs. 


Neurasthenia, subinvolu- 
tion, lacerated cervix, 
uterus atrophic 1 yr. 2 
mos. after dodging. 



THE MENOPAUSE 
THE MENOPAUSE. — {Continued.) 



605 



6 


6 

g 


6 


«j.2 


i — '"^03 

O c3_0 


> m cl) 




O M 

fs.§ 
3*" 


Leading symptoms and 


fc 


<3 


bj() 

< 


o 




all 

< 


<V &J0 bo 


diagnosis. 


6. 


N.M.C. 


45 


Mar. 


lch. 
13 yrs. 


... 


35 


10 yrs. 


Irritating leucorrhea, va- 
ginitis, uterus normal in 


7. 


J.E.C. 


46 


Mar. 


6ch. 

youngest 
10 yrs. 


45f 






size. 
Eczema of knees, face, and 
arms, neurasthenia, re- 
lieved since menopause, 
retroversion, lacerated 
cervix and perineum. 


8. 


D. D. 


42 


Mar. 


6ch. 

youngest 

7 yrs. 




41 


lyr. 


Frequency of micturition, 
lacerated cervix and 
perineum, prolapse. 


9. 


A.M.G. 


55 


Mar. 


No. ch. 
No. ab. 


44i 


40 


4J yrs. 


Flowing, retroversion, ec- 
zema of vulva. 


10. 


M.F.H. 


49 


Mar. 


5ch. 

youngest 
8 yrs. 




48 


3 mos. 


Retroflexion, subinvolu- 
tion of vagina. 


11. 


M.H. 


41 


Mar. 


3ch. 

youngest 
18 yrs. 




40 


5mos. 


Headaches, hot flashes, 
retroversion, lacerated 
cervix. 


12. 


E.G.H. 


50 


Mar. 


2ch. 

youngest 
25 yrs. 


48 


46 


2 yrs. 


Indigestion, rheumatism, 
uterus atrophic, pro- 
lapse. 


13. 


A. K. 


47 


Mar. 


3ch. 

youngest 
23 yrs. 


46J 






Hot flashes, lacerated cer- 
vix and perineum, 
through sphincter. 


14. 


L. L. 


48 


Sing. 


No ch. 
No ab. 


43 






Pain in abdomen and 
back, frequent micturi- 
tion, retroversion. 


15. 


G. M. 


44 


Mar. 


lch. 
23 yrs. 




42 


2 yrs. 


Nervous invalid 23 years, 
tubo-ovaritis for 23 
years. 


16. 


M.C.M. 


46 


Mar. 


No ch. 
Noab. 


... 


45i 


7 mos. 


Flowing, retroversion. 


17. 


D.L.M. 


41 


Sing. 


Noch. 

No ab. 




39 


2 yrs. 


Hysteria for many years, 
appendicitis, ovaries 
atrophic at operation. 


18. 


R.H.B. 


56 


Mar. 


lch. 

27 yrs. 


50 






Leucorrhea, frequency of 
micturition, cystocele, 
hemorrhoids. 


19. 


A. S. 


56 


Mar. 


No ch. 
Noab. 


51 


43 


8 yrs. 


Dyspareunia from erosion 
of fourchette, frequent 
micturition, atrophic 
uterus. 


20. 


L. S. 


49 


Mar. 


7ch. 

youngest 

15 yrs. 




48 


2 yrs. 


Hot flashes, dizziness, 
flowing, subinvolution, 
lacerated cervix. 


21. 


L. S. 


51 


Sing. 


No ch. 
No ab. 


50i 


45 


6 yrs. 


Lifelong neurasthenia, re- 
troversion. 


22. 


M.W. 


41 


Sing. 


No ch. 
No ab. 


41 


39 


2 yrs. 


Neurasthenia, atrophic 
uterus. 


23. 


M.A.W. 


48 


Mar. 


7ch. 

youngest 

17 yrs. 




46^ 


H yrs. 


Sense of prolapse, retro- 
version, lacerated cervix 
and perineum, ovaries 



606 



THE MENOPAUSE AND OLD AGE 

THE MENOPAUSE. — {Continued.) 



6 


q5 

a 


<v 


3.9 


^T3 m 


d 

CD CO • 

fe 2 ^ 
> d 03 




O M 
.d.5 <u 

|5- 


Leading symptoms and 


fc 


c3 


< 


o'-S 

o 
o 


O Cm 
. <L> O 


m CD c3 

Sag 




diagnosis. 














• 




atrophic at operation, 
uterus not. 


24. 


L. S. 


45 


Mar. 


2ch. 

youngest 

10 yrs. 


44 




None 


Excitable, can't control 
herself, retroversion, 

• atrophic uterus and 
vagina. 


25. 


KM. 


52 


Mar. 


4ch. 


48 


44 


4 yrs. 


Flowing for 2 years of 








[youngest 








dodging time, hot flash- 










16 yrs. 








es, stricture of urethra. 


26. 


M. L. 


43 


Mar. 


6ch. 

youngest 

6 yrs. 


43 






Burning in vulva, retro- 
flexion, lacerated cervix 
and perineum, caruncle. 


27. 


H. C. 


51 


Mar. 


1 ch. 

31 yrs. 


51 


46 


5 yrs. 


Asthma, heart disease, 
subinvolution, lacerated 
cervix, uterus still large 
11 years later. 


28. 


N.F.L. 


48 


Mar. 


3ch. 

youngest 
18 yrs. 




47 


1 yr. 


Flowing, subinvolution, 
lacerated cervix. 


29. 


W. H. 


50 


Mar. 


12 ch. 

youngest 
7 yrs. 


46 


41 


5 yrs. 


Neurasthenia, retroflexed 
senile uterus, proctitis. 


30. 


E. C. 


46 


Mar. 


No ch. 

No ab. 


45 


44* 


6 mos. 


Frequent and painful 
micturition, urethritis, 
debility. 


31. 


M.E.H. 


57 


Mar. 


2ch. 

youngest 

37 yrs. 


50 


• • • 




Hot flashes since meno- 
pause, depression, ure- 
thritis. 


32. 


M.I. 


56 


Mar. 


8ch. 

youngest 
17 yrs. 


49 




None 


Headaches, dyspnea with 
menopause, cancer of 
cervix, flowing for 6 
weeks, ovaries and tubes 
atrophic at operation. 


33. 


J. S. 


59 


Sing. 


No ch. 
Noab. 


55 


53i 


Hyrs. 


Enlargement of abdomen, 
cancer of ovary (large 
cystoma). 


34. 


B.C. 


45 


Mar. 


8ch. 

youngest 

6 yrs. 


44i 


434 


lyr. 


Pregnancy suspected, ec- 
zema of vulva, subin- 
volution, retroversion. 


35. 


0. L. 


46 


Mar. 


No ch. 

No ab. 

3ch. 




43 


3 yrs. 


Flowing, polypi in cervix. 


36. 


O.A.B. 


46 


Mar. 


45J 






Hot flashes, incontinence 










youngest 








of urine, rheumatism, 










24 yrs. 








hemorrhoids, subinvolu- 
tion. 


37. 


C. T. 


46 


Mar. 


2ch. 

youngest 

12 yrs. 


45i 






Flowing for two months, 
retroflexion, lacerated 
cervix and perineum. 


38. 


M. R. 


52 


Mar. 


2ch. 

youngest 
22 yrs. 




51 


8 mos. 


Pain in thigh, retroflexion, 
polypi, proctitis, sciat- 
ica. 


39. 


J.G.B. 


59 


Mar. 


3ch. 


50 






Frequent micturition, re- 
troversion, stenosis of 
canal. 



THE MENOPAUSE 

THE MENOPAUSE. — {Continued.) 



607 



6 


a5 


05 


s| 




si v — 

5g£ 




O m 


Leading symptoms and 


fc 


c3 


< 


o'-S 

O 

o 


. ?> o 




< 




diagnosis. 


40. 


G.P.P. 


57 


Mar. 


4ch. 

youngest 

27 yrs. 


50 






Leucorrhea, endometri- 
tis, cervix atrophic, uter- 
ine cavity 3^- inches. 


41. 


C.A.N. 


52 


Mar. 


lch. 

15 yrs. 




51J 


6 mos. 


Indigestion, headaches, 
tubo-ovaritis, anemia. 


42. 


S. H. 


56 


Mar. 


1 ch. 

32 yrs. 


48 


47 


1 yr. 


Leucorrhea 1 year, pain in 
groin 1 year, cancer of 
cervix, atrophic vagina. 


43. 


E. S. 


57 


Mar. 


3ch. 


54 






Vaginismus, headaches, 
cicatrix in perineum, le- 
sion of central nervous 
system. 


44. 


CD. 


50 


Mar. 


4ch. 

youngest 

15 yrs. 


49 






Watery leucorrhea for two 
months, cancer of cervix. 


45. 


A. J. 


50 


Mar. 


5 ch. 

youngest 
12 yrs. 


43 




None 


Endometritis, uterus and 
vagina atrophic, hemor- 
rhoids, leucorrhea. 


46. 


E. H. 


49 


Mar. 




44 






Foul leucorrhea for two 
months, cancer of cervix. 


47. 


M.A.S. 


45 


Sing. 


No ch. 
No ab. 


41 




None 


Cystocele and prolapse, 
cancer of ovary, breast, 
and liver later. 


48. 


M.N. 


51 


Mar. 


8ch. 

youngest 

18 yrs. 


43 






Painful lump in abdomen 
for 6 months, colloid 
carcinoma of ovary, 
lacerated perineum, 
gradual cessation of 
menses. 


49. 


C. T. 


55 


Sing. 


No ch. 
No ab. 


52 


52 


3 mos. 


Pain in vulva, urethral 
caruncle, senile atro- 
phic uterus and vagina. 


50. 


H. 0. 


42 


Mar. 


No ch. 
No ab. 




40 


2 yrs. 


Pain in bowels, tubo-ovar- 
itis, lacerated cervix. 


51. 


M.A.R. 


49 


Mar. 


2ch. 

youngest 

20 yrs. 


43 






Foul leucorrhea for six 
weeks, cancer of cervix, 
prolapse 12 years ago. 


52. 


W.P.M. 


52 


Mar. 


2ch. 

youngest 
26 yrs. 


45 






Ovarian cystoma with 
purulent contents, acute 
peritonitis. 


53. 


C.E.'O. 


49 


Sing. 


No ch. 

No ab. 




48 


3 mos. 


Neurasthenia, retrover- 
sion, under observation 
3 years. 


54. 


M. S. 


44 


Mar. 


6ch. 

youngest 

h\ yrs. 


43 






Incontinence of urine, diz- 
ziness, dislocation of 
urethra downwards. 


55. 


E.J.S. 


51 


Mar. 


4ch. 

youngest 
25 yrs. 


50 


49! 


6 mos. 


Headaches, flowing, retro- 
version, endometritis. 


56. 


N. H. 


43 


Mar. 


No ch. 
Noab. 


43 


42 


1 yr. 


Hot flashes for first 6 
months of dodging time, 
subinvolution. 



608 THE MENOPAUSE AND OLD AGE 

THE MENOPAUSE. — {Continued.) 



6 


o5 


<v 


d 

.1-2 


•d d 5 


a 

> TO 0) 

> fl TO 




«4-l 


Leading symptoms and 


fc 




< 


02 n 
o 


OS'S 
O <-<£} 




trt M 

<» a v 




diagnosis. 


57. 


M. E. 


50 


Mar. 


2ch. 
voungest 
"30 yrs. 


45 






Hot flashes, rheumatism, 
. vaginitis, uterus atro- 
phic. 


58. 


S. M. 


57 


Mar. 


7ch. 

•youngest 
17 yrs. 


54 






Sense of prolapse, subin- 
volution, vaginitis. 


59. 


J. P. 


59 


Mar. 


5ch. 

youngest 
24 yrs. 


50 






Flowing at menopause, 
headaches before, pain 
in abdomen, lacerated 
cervix and perineum. 


60. 


J.A.A. 


46 


Mar. 


4ch. 

youngest 

20 yrs. 




45 


i yr- 


Rheumatism, procidentia, 
lacerated cervix and per- 
ineum, ovaries normal at 
operation. 

Flowing for six months, 


61. 


C. B. 


48 


Mar. 


14 ch. 


42 








Colored 






youngest 
17 yrs. 








cancer of cervix, ad- 
vanced. 


62. 


M. B. 


58 


Mar. 


5ch. 

youngest 

28 yrs. 


53 






Flowing for one month, 
multilocular papillary 
cystoma of ovaries. 


63. 


M. B. 


49 


Mar. 


6ch. 

youngest 

18 yrs. 


48 


48 


4 mos. 


Headaches, retroversion, 
lacerated cervix and per- 
ineum, pyosalpinx, ova- 
ries normal at operation. 


64. 


M.C. 


58 


Mar. 


7ch. 

youngest 

20 yrs. 


40 






Rheumatism, rectocele, 
cystocele, atrophic va- 
gina. 


65. 


M. C. 


45 


Mar. 


2ch. 

youngest 

10 yrs. 


37 






Occasional hot flashes, ure- 
thral caruncle. 


66. 


M. C. 


48 


Mar. 


5ch. 
youngest 

8 yrs. 


44 






" Falling of womb " eight 
years, prolapse. 


67. 


J. D. 


52 


Mar. 


6ch. 

youngest 
20 yrs. 


42 






Unable to control bowels, 
lacerated perineum 
through sphincter, pol- 
yp, urethral caruncle. 


68. 


S.J. 


50 


Mar. 


2ch. 


50 


48^ 


2iyrs. 


Tubo-ovaritis, uterus 
atrophied at operation, 
ovaries and tubes not, 
according to pathologist. 


69. 


M.J. 


59 


Mar. 


lch. 
31 yrs. 


50 


43 


7 yrs. 


Flowing during dodging 
time, abdominal tumor, 
lacerated cervix. 


70. 


B. L. 


53 


Mar. 


10 ch. 


m 






Painful micturition, ure- 
thritis, urethral caruncle. 


71. 


C. L. 


49 


Mar. 


3ch. 

youngest 
22. V yrs. 


45 


42 


3 yrs. 


Scalding at vulva, eczema 
of vulva. 


72. 


A. L. 


53 


Sing. 


No ch. 
Noab. 




49 


4 yrs. 


Painful defecation, hem- 
orrhoids, partial atrophy 
of uterus. 



THE MENOPAUSE 

THE MENOPAUSE. — (Continued.) 



609 



d 


d 

a 


d 


d 


1-1 -h +» 


d 

<D GO • 

t MB 

> a v> 


!i?d 


O feo 

^.2 d 


Leading symptoms and 


fc 


<3 


< 


o 


O ^ !h 

o> o 
d£-^ 


< 


^ ^ 




diagnosis. 


73. 


F.J.M. 


57 


Mar. 


No ch. 
1 ab. 


48 


47 


1 yr. 


Hot flashes and headaches 
during dodging time, 
cystitis, proctitis, retro- 
flexion. 


74. 


E.M.D. 


42 


Sing. 


No ch. 
No ab. 




42 


3 mos. 


Hysteria, hot flashes, retro- 
version, adherent pre- 
puce, masturbation. 


75. 


M. M. 


49 


Mar. 


lch. 
14 yrs. 


44 






Flowing for one year, ab- 
dominal cancer, lacer- 
ated cervix and peri- 
neum. 


76. 


A. F. 


50 


Sing. 


No ch. 
No ab. 


47 




None 


Nervous headaches since 
menopause, hemorrhoids. 


77. 


A. F. 


49 


Mar. 


No ch. 

No ab. 


42 






Tumor in abdomen for 
twelve years, dermoid 
ovarian cystoma. 


78. 


E.F. 


56 


Mar. 


4ch. 

youngest 

22 yrs. 


46 






Yellow leucorrhea for one 
and a half years. Tuber- 
culosis of endometrium, 
ovaries and tubes atro- 
phic at operation. 


79. 


S. G. 


47 


Sing. 


No ch. 
No ab. 


46 


44 


2 yrs. 


Flowing two months, ma- 
lignant adenoma of uter- 
us, cervix and vagina 
atrophic. 


80. 


L.G. 


48 


Mar. 


6ch. 

youngest 

14 yrs. 


45 






Flowing, polyp, subinvo- 
lution, lacerated cervix 
and perineum, cardiac 
disease. 


81. 


F.H. 


46 


Mar. 


6ch. 


441 




None 


Flowing for six months, 
uterine polyp. 


82. 


M. H. 


53 


Mar 


10 ch. 


52 






Pain in pelvis, dizziness, 
urethritis, cystitis, va- 
ginitis. 


83. 


H.J. 


45 


Sing. 


No ch. 
No ab. 


45 






Flowing, fungous endo- 
metritis. 


84. 


J. M. 


49 


Mar. 


No ch. 
1 ab. 




47 


2 yrs. 


Flowing for two years, 
hyperplastic endometri- 
tis. 

Painful and bloody mictu- 


85. 


M. M. 


52 


Mar. 


lch. 


42 














25 yrs. 








rition, stone in bladder, 
prolapse. 


86. 


M. M. 


42 


Mar. 


2ch. 

youngest 

6 yrs. 


40 






Frequent micturition and 
bearing down, polyp, 
lacerated cervix and 
perineum. 


87. 


J.P.M. 


52 


Mar. 


No ch. 
No ab. 


50 






Flowing for two years, ad- 
eno-carcinoma of cervix. 


88. 


M. M. 


55 


Mar. 


9ch. 


49i 






Sense of prolapse, pro- 
lapse. 


89. 


D. 0. 


52 


Mar. 


12 ch. 

youngest 

19 yrs. 


44 






No symptoms at meno- 
pause, retroversion, tu- 
mor of pelvis. 



39 



610 



THE MENOPAUSE AND OLD AGE 

THE MENOPAUSE. — {Continued.) 



o 


B 


<u 


d 
■33 


A C g 

O c3 O 


> rt w 






Leading symptoms and 


& 


< 


o 
o 


. <D O 
£^C3 


o>2 £ 
<1 




3-g-I 


diagnosis. 


90. 


M.L.P. 


55 


Mar. 


No ch. 

No ab. 


50 


48 


2 yrs. 


Indigestion, frequency of 
micturition, atrophic 

uterus. 


91. 


M. P. 


58 


Mar. 


2ch. 


50 


49 


1 yr. 


Incontinence of urine, tu- 
mor of vagina six 
months, malignant ade- 
noma of vagina. 


92. 


A. R. 


49 


Mar. 


6ch. 


44 






Painful micturition, lacer- 
ated cervix and peri- 
neum, uterus atrophic at 
ether examination. 


93. 


H. D. 


50 


Mar. 


7ch. 
6ab. 


48 






Flowing for one and a half 
years, subinvolution, 
endometritis. 


94. 


J. G. S. 


52 


Mar. 


1 ch. 

20 yrs. 


50 


48 


2 yrs. 


Hot flashes for four or five 
years, lacerated peri- 
neum, intestinal catarrh. 


95. 


L. S. 


45 


Mar. 


2ch. 

youngest 
10 yrs. 


44 


* • • 


None 


Hot flashes, urethritis, 
dislocation of urethra 
downward. 


96. 


L. S. 


48 


Mar. 


7ch. 

youngest 
15 yrs. 




47 


1 yr. 


Dizziness, pain in left side, 
subinvolution, lacerated 
cervix, endometritis. 


97. 


F.L.S. 


49 


Mar. 


3ch. 

youngest 
16 yrs. 




48 


1 yr. 


Frequent micturition, sub- 
involution, urethritis, 
cystitis. 


98. 


E. S. 


47 


Mar. 


lch. 
27 yrs. 




45 


2 yrs. 


Flowing, subinvolution, 
polyp. 


99. 


J. W. 


46 


Sing. 


No ch. 
Noab. 




441 


H yrs. 


Leucorrhea, headaches, re- 
troversion, vaginitis, old 
pelvic inflammation. 


100. 


L. R. 


52 


Mar. 


3ch. 

youngest 
15 yrs. 


50 






Flowing for three weeks, 
lacerated, cervix and per- 
ineum, polyp, fistula in 


101. 


M.E.L. 


52 


Mar. 


3ch. 


51 






ano. 
Prolapse, lacerated cervix 
and perineum. 


102. 


B.C. 


56 


Mar. 


1 ch. 
20 yrs. 


51 






Flowing for six months, 
cancer of body of uterus. 


103. 


M. C. 


50 


Mar. 


9ch. 

youngest 
10 yrs. 




49 


8 mos. 


Sense of prolapse, lacer- 
ated cervix and perine- 
um, procidentia. 


104. 


M. D. 


48 


Sing. 


No ch. 
Noab. 




47 


1 yr. 


Flowing for one year, 
polyp. 


105. 


A.C. 


49 


Mar. 


8ch. 


48 






Sense of prolapse, lac- 
erated cervix and peri- 
neum, prolapse. 


106. 


M. D. 


54 


Mar. 


3ch. 


48 






Can't control bowels, lac- 
erated cervix and peri- 
neum through sphincter. 


107. 


J. M. 


52 


Mar. 


10 ch. 

youngest 

7 yrs. 


50i 






Prolapse, lacerated cervix 
and perineum. 



THE MENOPAUSE 

THE MENOPAUSE. — {Continued.) 



611 



6 


6 
B 


to 


■35 




d 

d) CO • 

cj CO 


1 M • 


1H 
O hfl 

pd.5 o> 


Leading symptoms and 


fe 


c3 


< 


OT3 
O 


o d-g 
• go 

8*s 


o) ^ S^ 


O) % ^ 


Jl* 


diagnosis. 


108. 


L. D. 


46 


Sing. 


1 ch. 
12 yrs. 


44 






Prolapse, lacerated cer- 
vix and perineum, uter- 
us and ovaries atrophic. 


109. 


B.B. 


54 


Mar. 


2ch. 


44 






Leucorrhea and sense of 
prolapse, cystocele and 
rectocele. 


110. 


M. D. 


52 


Mar. 


No ch. 
lab. 


48 






Flowing two and a half 
years, uterus large, spin- 
dle-celled sarcoma of 
ovary. 


111. 


C.N. 


54 


Mar. 


7ch. 


47 




None 


Painful and bloody mictu- 
rition two months, can- 
cer of bladder. 


112. 


A.H. 


48 


Sing. 


No ch. 
No ab. 


45 


... 




Flowing for six months, 
cancer of body of uterus. 


113. 


M.E.T. 


56 


Mar. 


2ch. 

youngest 
32 yrs. 


50 






No complaint except pro- 
lapse, lacerated peri- 
neum. 


114. 


M. M. 


57 


Sing. 


No ch. 
No ab. 


51 






Acute obstruction of bow- 
els, cancer of sigmoid. 


115. 


B.D. 


54 


Mar. 




44 






Pain in abdomen, cysto- 
ma of left ovary, right 
ovary atrophic at oper- 
ation. 



The Dodging Time 

Tilt and others have called the time from the beginning of ir- 
regularity of the menses to their cessation, the dodging time. In 
his 500 tabulated cases there was no dodging time in 137 women, 
menstruation stopping suddenly in these. The average length of 
the dodging time in 265 cases was 2.2 years. In my own list, data 
as to the length of the dodging time were obtained in 62 cases. 
Of these 8 had no dodging time and of the 54 remaining the 
average time was 2.2 years. However, of these the dodging time 
was surely completed in only 23 and in these the average was 2.8 
years, the longest 10 years, and the shortest 3 months. 

I think we should agree with Tilt that very little can be deduced 
as to the normal dodging time from these figures. Sudden cessation 
of the menses is of comparatively infrequent occurrence. In many 
of the women there was noted an alteration in either or both the 
quantity and the quality of the menstrual blood, also certain 



612 THE MENOPAUSE AND OLD AGE 

phenomena such as hot flashes and nervous instability, previous 
to the beginning of irregularity of rhythm, so that the inference is 
justified that ovarian influence begins to fail before menstruation 
becomes irregular. 

Two years and nine and a half months (2.8 years) represents the 
average duration of the dodging time as influenced by uterine or 
ovarian disease in my series of cases; hardly enough cases to warrant 
any weighty conclusions, however. We know nothing about the 
factors that govern a sudden or a prolonged menopause, and we 
have no means of knowing in any given case what the issue is likely 
to be. 

We speak of the menopause being over, or passed, when the 
genital hemorrhages have ceased. Of course, this is not necessarily 
the case, for the changes in both the body (the uterine organs and 
the system at large) and in the psychical state of the individual 
that are peculiar to the menopause may be only begun when the 
menses cease. On the other hand, these general phenomena may 
precede the disappearance of the menses; therefore we might, 
perhaps, mark the beginning and the end of the climacteric by the 
appearance and the cessation of these phenomena, rather than by 
the stopping of menstruation. 

Phenomena of the Menopause in Body and Mind 

Leaving for consideration in the succeeding section the influence 
of diseased uterine organs on the menopause, let us examine here 
the manifestations of the change of life in the other portions of the 
body. 

Cardio- vascular System. — Hot Flashes.— -Hot flashes, or flushes, 
are probably the most frequent and the most annoying of the 
symptoms of the menopause. In a well-developed hot flash the 
patient at first feels hot, some portion of the skin of the body, 
generally the face and hands, being suddenly filled with blood; 
a sort of exaggerated blush. Immediately afterward sweating 
occurs and finally the patient feels cold, the chilly sensation coming 
on either while the sweating is in progress or after it has ceased. 
The vigor with which these flashes seize the individual vary greatly 
in different patients and in the same patient at different times. 
Also the frequency of their recurrence varies from as many as ten 



THE MENOPAUSE 613 

an hour in one case of artificial menopause, reported by Bland- 
Sutton ("Surgical Diseases of the Ovaries and Fallopian Tubes/' 
p. 486) to an occasional irregular flash. No two cases are alike and 
there seems to be no definite relation between the sudden occurrence 
of the menopause and the severity or frequency of the flashes, except 
that in the case of the artificial menopause the flashes are generally 
more severe. Ordinarily the flashes are most severe in the beginning 
when the menses first become irregular and gradually, as the months 
go by, are less and less pronounced. 

Tachycardia and High Arterial Tension. — Paroxysmal increase 
in the rapidity of the heart's action and a general high arterial 
tension have been observed in women at the menopause. These 
disturbances are, as in the case of the hot flashes, due to derange- 
ment of the vaso-motor nervous mechanism. They may be due to 
preexisting heart disease, but occur in women who have no dis- 
coverable heart lesion. Stokes first called attention to them and 
they have been studied more recently by Kisch (Berlin, klin. 
Woch., 1889), Fiessinger (Journ. des Praticiens, 1902, p. 802), 
Pawinski ("Tension arterielle dans la menopause," Acad. Med., 
1904), and L. Williams (Clin. Journ., March. 3, 1909, Vol. XXXIII., 
p. 329). If we assume that a manometric reading of the pulse 
just before a normal menstrual period of 130 to 150 millimeters 
of mercury represents the highest average during sexual life (the 
lowest being about 110 millimeters just after a menstrual period) 
the manometer may show a blood pressure of 180 millimeters in 
the pulse of a woman who is passing through the menopause. The 
pulse feels bounding and full. The patient complains of palpita- 
tion, which is often especially annoying at night and is accompanied 
by smothering sensations. Sometimes in marked cases there is 
active dyspnea, the respiration becoming embarrassed at the least 
effort. The pulse rate may be as high as 150 or 160 a minute and 
sometimes it is also irregular, even in cases where organic heart 
disease can be absolutely excluded. 

The Nervous System. — The phenomena of derangement of function 
of the vascular system that have been described already are un- 
doubtedly caused by some unknown impairment of the nervous 
mechanism. Other indications of functional nervous disease are 
intercostal neuralgia, insomnia, ringing in the ears, loss of memory, 
suspicions, and change in character, especially by developing irri- 



614 THE MENOPAUSE AND OLD AGE 

tability of temper. The small every-day annoyances assume ex- 
aggerated importance and become insupportable. Many women 
from being of a ■ cheerful disposition become habitually sad and 
depressed. The thought is forced upon us that this state of mind 
is in part due to the gloomy views about the change of life that 
have been held by both laity and the profession in the past. To 
some women we can imagine that the knowledge that the child- 
bearing function is going, that she is becoming unsexed, is a dispirit- 
ing thought. If in addition sexual pleasures have been an important 
feature of her life the disappearance of these may be an added 
source of melancholy. Vinay (loc. cit., p. 107) thinks that such a 
thought caused Mme. du Deffant to remark with regret, " Formerly, 
when I was a woman." 

Neurasthenia is a common accompaniment of the menopause 
but, more often than not, does not originate at that time. Many 
nervous stigmata long existent, perhaps inherited but not noticed 
by either the patient or her physician, come to the fore at the 
change of life. Hysteria is developed sometimes at the menopause, 
but here in a majority of cases a careful sifting of the history will 
detect stigmata as having been present in the past. 

Sexual Feeling at the Menopause. — This subject has been studied 
by Brierre cle Boismont, Gueneau de Mussy, and other French writers. 
It would appear that there exists in many women an excess of sexual 
passion at the close of the menstrual life in not only the married 
but in widows and the unmarried. This is shown by platonic 
affections, by a morbid attraction for the opposite sex, young boys 
even being selected as the objects of lavish attentions, or by mas- 
turbation, nymphomania, or excessive lustfulness. Venereal 
desires become a positive obsession in some women and they may 
affect those who have not experienced them previously during 
their lives. Sexual feelings are apt to be manifest at the times 
when menstruation should occur and the seizures, which are of 
short duration, but perhaps often repeated, seem to replace the 
periods. They are accompanied often by hypochondria and melan- 
choly. At the conclusion of the menopause sexual feeling gen- 
erally disappears, though it may not. R. G. Hann (Journ. Obstet. 
and Gyn. of British Empire, 1902, Vol. II., p. 290) reports the 
unusual case of a woman, the mother of twelve children, who 
ceased to menstruate at forty-six years. Then all sexual feeling 



THE MENOPAUSE 615 

was lost. Three years later she gave birth to her thirteenth child 
and sexual feeling returned with the first menstrual period. 

Mental Diseases. — Many diseases of the nervous system are 
separated by such a delicate line from the diseases of the mind 
that their differentiation is often a matter of great difficulty. In 
the first place it may be best to state that there is no such thing as 
climacteric insanity in the opinion of such an authority on insanity 
as M. Craig, of the West Riding Asylum in England. Of the two 
hundred and twenty-two cases of insanity during the menopause 
occurring in the West Riding and Bethlehem asylums in ten years, 
(Journ. of Mental Science, 1894, Vol. XL., p. 236) between 63.3 
and 68.6 per cent, respectively, were cases of melancholia. H. 
Berger, of Jena (Monatss. filr Psychiatrie u. Neurol, 1907, Bd. 
XXII., Erganz. Heft 13), reports a similar conclusion from a series 
of fourteen cases which he has studied and a review of the literature, 
and this corresponds with the experience of most writers on mental 
disease that melancholia is most often observed at this time of 
life. The other diseases with their respective percentages observed 
by Craig were as follows: — 

Mania, 15-18 ; Weak-mindedness, 2-1 ; 

Delusional insanity, 9-14; General paralysis, 2-1. 

He attributes an important influence to heredity in the causation 
of mental disease at this time, and points out that the menopause 
has a deleterious effect on preexisting psychoses; therefore, from 
this point of view, we are justified in classing the menopause as a 
critical time of life. We must remember, however, that the patients 
who happen to be in the insane asylums during the climacteric 
years, are only a small proportion of all women of that age in the 
community, and that the causative agency of the menopause in 
producing mental disease is still most indefinite. 

The Alimentary Canal. — Eisner found in the stomachs of men- 
struating women hyperchlorhydria that he attributed to hyperemia 
of the gastric mucous membrane coincident with the hyperemia of 
the uterine mucosa. At the menopause there is often found an 
atonic gastritis with hyperchlorhydria. Dyspepsia of one kind or 
another is frequently observed at the menopause, especially among 
American women where dyspepsia is such a common disease at all 
ages. Patients suffer with epigastric pain and heartburn two or 



616 THE MENOPAUSE AND OLD AGE 

three hours after eating. There are acid eructations and some- 
times vomiting and constipation. Gallard, according to Vinay, 
called attention to the penchant that many women have during the 
menopause for strong liquors and assigned part of the dyspepsia 
to an alcoholic habit. Chronic gastro-enteritis may be the cause 
of obstinate constipation which is common at the menopause. 
Puech found hematemesis as a vicarious menstruation in some 
of his women, but other authors do not mention it. 

The Nutrition. — Obesity appears in certain young girls of a 
lymphatic type as they reach puberty. It is also often observed in 
women after prolonged lactation, and it is a very frequent con- 
comitant of the menopause, either normal or artificial. The same 
increase in fat is seen in capons, oxen, and other castrated animals. 
Most of the fat is deposited in the panniculus adiposus of the 
anterior abdominal wall, over the breasts, the buttocks and the 
hips, and less in the limbs and face. The abdomen gets larger at the 
menopause both because of the excessive accumulation of adipose 
tissue in the anterior abdominal wall, and also because of the 
deposit of fat in the mesentery of the intestine and in the omentum, 
perhaps accompanying gastro-intestinal disturbances with chronic 
flatus. The increase in body size due to obesity at the menopause 
is seldom excessive. 

Where loss of flesh accompanies the menopause, as it occasionally 
does, we look for some definite fault of nutrition. Anemia occurs at 
the climacteric especially in those women who have lost much blood 
as a result of uterine hemorrhages. There are pallor of the face and 
lips, shortness of breath on the slightest effort, indigestion, hemic 
murmurs over the precordia, and headaches and nervous irritability. 

Rheumatism.— F. Neumann (Med. Klin., Berlin, 1908, Vol. IV., 
p. 407), physician to the baths of Baden-Baden where 3,158 women 
with joint disease (acute and chronic rheumatism of the joints, 
arthritis deformans, and gout) were treated in the seven years from 
1901 to 1907, inclusive, notes the frequency of the association of 
chronic joint disease with the menopause. He has found that many 
women with chronic joint disease date the beginning of their ailment 
from the climacteric or the time just after it. He had seen forty- 
seven cases of this relation in the previous two years and a case 
where joint affections had been associated with the menopause 
artificially induced by castration. Whether the occurrence of 



THE MENOPAUSE 617 

rheumatism at this time has to do with deficient elimination of 
waste products because of changes in the excretory glands of the 
body at the menopause, as assumed by many writers, is still sub 
judice. The urinary function seems to be impaired and deficient 
elimination with lithiasis occurs in some cases. 

The Skin. — Pruritus and eczema are most common at the meno- 
pause and are frequently localized in the region of the vulva or anus. 
Urticaria and acne rosacea are not infrequently seen. Growth of 
hair, especially on the chin, the upper lip, and about the breasts, is 
sometimes observed at this time. 

The diseases of the breasts have been considered in Chapter 
XXVII, page 531. 

Influence of Uterine Diseases on the Menopause 

A certain relatively few uterine diseases originate at the meno- 
pause, such as injuries to an atrophic vagina from coitus, pruritus 
vulvae, and prolapse. A large majority, however, have their origin 
long before the menses begin to be irregular, even though they may 
have previously excited little attention from either the patient or 
the physician. 

Hemorrhages. — Let us consider first the pathological conditions 
which give rise to hemorrhages at the menopause. 

(a) Fibroids. — The most frequent of these are fibroids of the 
uterus in situation either submucous or interstitial. The bleeding 
in such cases is apt to begin as menorrhagia occurring after the 
thirty-fifth year, gradually becoming greater in amount, and finally 
resulting in metrorrhagia as the patient enters the forties. Ab- 
dominal or pelvic pain may accompany the flow; it may be in- 
dependent of it or it may be absent. Expulsive, labor-like pains 
are present sometimes when a submucous nodule is being driven 
out of the uterus. More often the uterus becomes atonic from the 
prolonged presence of the foreign body and the patient experiences 
no pain. The subject of fibroid tumors is described at length in 
Chapter XV., page 244. It is enough here to counsel a thorough 
local examination in the case of every woman who has excessive 
flowing at or about the menopause. We know that, although some 
fibroid tumors diminish in size and cause no symptoms after the 



618 THE MENOPAUSE AND OLD AGE 

menopause has been established, the majority do not atrophy, and 
even if they do they are subject to a variety of degenerative changes 
that jeopardize the health or even the life of the patient. Not only 
that, but the change of life is delayed in the possessors of fibroid 
uteri and the loss of strength from prolonged and repeated hemor- 
rhage, with its consequent anemia, constitutes a handicap from 
which many untreated women never recover. Others, hardier, 
the more rapid blood-makers, survive the drain on their vitality 
and are able to get back into good condition after a series of years 
of invalidism, and still others, the very tough sort who can stand 
anything, are not seriously incommoded. 

(b) Subinvolution. — The next most frequent cause of hemorrhages 
at the climacteric is the condition known variously as subinvolution 
or chronic metritis, with or without lacerated cervix. In looking over 
my list of cases of women who were either passing through or had 
passed the menopause (see pages 604—611) I find the diagnosis of 
subinvolution or badly lacerated cervix noted in thirty-five of the 
ninety parous women in the list. Not all of these suffered with 
flowing, but it is plain that if the uterine muscle has been replaced 
by connective tissue or elastic tissue and has acquired an increased 
bulk because of these changes in its tissues brought about by 
chronic engorgement, the retrograde alterations in its structure 
which normally take place at the menopause are hindered, so that 
the organ can not shrink to the diminutive size found in old age 
under non-pathological conditions, except after a longer time and 
at the expense of disquieting local symptoms in the form of hemor- 
rhages and leucorrhea, and general symptoms as described in the 
last section. 

(c) Endometritis.— Endometritis occurring under the varieties 
of fungous, polypoid, and glandular, is a cause of both flowing and 
leucorrhea at the menopause in a considerable number of cases. 

(d) Polypi were found in ten of the cases in my list and other 
observers have found these frequently during the menopause, 
some authors in the past alleging that they were due to the change of 
life. Endometritis so often accompanies subinvolution that in an 
analysis one can not separate the two. We must regard the disease 
as originating in some infection long before the menopause, but as 
becoming the cause of hemorrhage and leucorrhea at that time 
because of the altered rhythm of the pelvic circulation. On account 



THE MENOPAUSE 619 

of the decreased vitality of the uterine organs at the menopause 
the opportunities for the entrance of infection into the tissues are 
enhanced ; therefore, it may well be the case that infections origi- 
nate at this time in the uterine endometrium as they do in the 
vagina. My observation leads me to think that in most instances of 
endometritis at the menopause the disease is an exaggerated stage 
of a preexisting endometritis. 

(e) Cancer of the Uterus. — In looking up my cases of women who 
were passing through the menopause I found in addition to those 
in the list four who had flowing because of cancer, — two each of 
cancer of the cervix and of cancer of the body. There is no evidence 
to prove that the occurrence of cancer, except in the late stages of 
the disease, has any more effect on the menopause than subin- 
volution. As previously stated, cancer is a disease of the atrophic 
tissues. In my list of one hundred and fifteen cases there are 
seven cases of cancer of the cervix and three of cancer of the 
body of the uterus, all ten presenting no symptoms until the 
menopause had been well established for ten months in the short- 
est time, and eight years in the longest. Thus we have ten cases 
of cancer of the uterus first manifesting its presence after the 
menopause was over, as contrasted with four cases diagnosed in 
women of the same ages, — forty-one to fifty-nine, — during the 
menopause. 

Before leaving the subject of hemorrhage at the menopause it 
may be proper to state that there are cases, although they are 
rare, in which no adequate explanation of flowing at the climacteric 
can be found either in the uterine organs or in the system at large. 
There is a probability, as suggested by Scanzoni long ago, that 
arteriosclerosis at this time of life, by rendering the blood-vessels 
of the uterus more rigid and friable so that they can not withstand 
increased blood pressure, predisposes to hemorrhage. Borner 
(loc. cit., p. 42) reports the following case of unexplained climac- 
teric flowing: "Mrs. R., aged sixty, had always menstruated 
regularly but profusely. She married at twenty-three and had 
three normal labors within seven years. She had always enjoyed 
good health except that she had a highly irritable nervous system. 
At forty-nine she suffered with a sudden and profuse flowing. 
Repeated local examinations failed to find any abnormality of the 
uterine organs and a general physical examination detected nothing 



620 THE MENOPAUSE AND OLD AGE 

wrong with the circulatory system. Repeated hemorrhages at 
longer or shorter intervals produced such profound anemia that 
she was obliged to pass two entire winters in bed. Then, at fifty-one, 
the hemorrhages ceased and she became strong and well as before. 
Another examination of the uterine organs at this time failed to 
reveal any abnormality." 

Displacements of the Uterus at the Menopause. — Displacements 
of the uterus at the menopause except prolapse are of minor impor- 
tance. Retroversion is a condition of the uterus that may be regarded 
as normal after the climacteric atrophy has taken place. Prolapse : 
A uterus made heavy by subinvolution is more apt to sag down and 
to become prolapsed at the menopause than before because of the 
weakening of the uterine ligaments and the disappearance of the 
muscular wall of the vagina, coupled with a shortening and change 
in shape of the vagina at this time. The cervix becoming smaller and 
the upper vagina assuming a narrowed caliber and a conical shape, 
the cervix no longer enters the latter organ with its long axis at a 
right angle to the long axis of the vagina, but is a button at the 
upper end of the shortened, flabby- walled vagina. 

Although only twelve of my one hundred and fifteen cases 
were affected with prolapse, the affection is common arnong the 
uterine diseases of the menopause. It occurs even in the virgin. 
Of this I remember having seen two cases. Borner (loc. tit., p. 64) 
cites the following case: "Miss G. had passed the menopause about 
ten years before. She had been free from any sort of abdominal dis- 
turbances during her entire life. She was in good health, although 
incommoded recently by getting fat. Shortly before, she happened 
to be assisting in moving a chest, something she had done many 
times previously, when she felt suddenly a pain in the abdomen, and 
at once noticed a foreign body between her thighs. Soon after she 
consulted me and I found a total prolapse of the uterus and vagina 
while in every other respect the genitals were intact. The patient 
was a nullipara and had accordingly an uninjured, firm perineum; 
the vagina, already somewhat narrowed by senile shrinking, was 
absolutely free from those changes (hypertrophy, a dry leathery feel 
of some portions, etc.) which would have pointed to a procidentia 
of long standing; the uterus was already atrophied and was small, 
light and thin-walled, and the cervix was absolutely intact." 
Such a case must be explained by increased intra-abdominal 



THE MENOPAUSE 621 

pressure coupled with the atrophic conditions of the uterine 
organs just described that favor prolapse. 

Cystocele and rectocele are frequently found at the menopause 
because of the weakening of the vagina by atrophic changes in its 
walls; therefore the walls are more apt to become pouched during 
the climacteric than they are previously when the muscular and 
tendinous tissues of the perineum and vaginal walls are in a tonic 
condition. 

Vaginitis and Injuries of the Vagina from Coitus. — A discussion of 
senile vaginitis will be found in Chapter XX., p. 365. Infection and 
inflammation of the atrophic vagina are not infrequently met during 
the menopause. The disease is more common, however, as a so- 
called post-climacteric phenomenon and will be considered under 
the diseases of old age. As previously stated, the non-elastic atro- 
phic vagina may be excoriated or even torn as a result of coitus. 
Chadwick reported a case of this sort in which a woman forty-eight 
years old, who had not menstruated for about ten years, indulged 
in sexual intercourse after having refrained from it for four months, 
with a result that she had violent pain and profuse hemorrhage. 
Examination showed a recent tear an inch long in the upper third 
of the vagina, extending into the cellular tissues to a depth of half 
an inch. The vagina, on account of senile atrophy, was consider- 
ably shorter and narrower than in the childbearing period. 

Eczema or pruritus vulvae was noted eight times in my list of 
cases and I remember having found these affections rather fre- 
quently during the menopause in dispensary practice. They may 
occur at other times and they are more frequently met in the post- 
climacteric period, — in old age, — than during the menopause. 
Pruritus may be independent of any known pathological lesion of 
the skin of the vulva, and is thought often to be a local manifes- 
tation of a lesion of the general nervous system. 

Vesical Symptoms. — Urinary symptoms were noted in twenty- 
three of my cases. The symptoms included frequent micturition, 
painful micturition, and incontinence of urine. A detailed analysis 
of the different diseases present is hardly worth while in such a 
small number of cases. The following were noted, however: 
urethritis, cystitis, dislocation of the urethra downward, and four 
cases of urethral caruncle. The menopause might act as a causative 
agent indirectly in producing urinary difficulties by the exaggera- 



622 THE MENOPAUSE AND OLD AGE 

tion of preexisting malpositions and traumatisms clue to child- 
bearing, or through the atrophy of the labia pudendi and the labia 
urethrse offering more easy access of pathogenic bacteria to the 
canal of the urethra. In addition to the local causative agents the 
unstable equilibrium of the nervous system at the menopause is 
to be reckoned with when considering the function of urination. 
How much the derangement of function is caused by actual disease 
of the urinary organs, and how much by disorder of the general 
nervous system, we find most difficult to state in many actual 
cases in practice. My observation leads me to the view that the 
situation is the same with the urinary apparatus as with the uterine 
organs; that preexisting disease, or impairment of function, causes 
a stormy change of life ; that unsound organs which, while nourished 
by a well-equalized blood supply, cause only minor symptoms, 
under changed conditions cry out loudly. Therefore, let it be our 
aim to discover the abnormalities of the genital organs during the 
period of sexual maturity in the life of our patients and, by treating 
the diseases, help the patients to avoid many of the discomforts 
of the menopause. 

OLD AGE 

Bichat, writing in 1800, said: "The man who has reached the 
end of a long career dies in detail; his visible functions end one 
after the other. " Woman apparently grows old faster than man and 
the exact reason can not be found. Women of tropical climes 
reach senility sooner than those of northern latitudes, just 
as the exuberance of vegetation in the torrid zones, after a 
season of forcing, comes to a climax and dies earlier than in the 
slower growth of the temperate regions. Hereditary predisposition 
of the individual to prolonged life, or to the longevity of certain 
functions of body or mind, must be considered in making a diagnosis 
and a prognosis in the case of any disease of advanced life. The 
menopause represents a phase of life which is introductory to old 
age. It is not, however, a part of old age, and, as has been said 
already in treating that period of life, is not to be credited with 
all the atrophic changes in the organs of the body which occur with 
advancing years. A good deal is said in the literature of the "post- 
climacteric phenomena." At the beginning of this chapter we 



OLD AGE 623 

adopted the age of sixty years as an arbitrary point for the be- 
ginning of old age, and although some of the post-climacteric 
changes in the organs of the body must in single instances antedate 
this age, still this mark is as good as any other for our purpose. 

This is not the place for a discussion of the alterations which 
take place, as a result of age, in the tissues and in the function of 
the heart and blood-vessels, the spleen, the thyroid and the supra- 
renal capsules, the nervous system, the digestive canal, the kidneys, 
the liver, the lungs, the skin, and the general nutrition. For an able 
exposition of these important considerations the reader is referred 
to Professor G. Rauzier's "Traite des Maladies des Vieillards," 
(Paris, 1909). Here it will be sufficient to call attention briefly 
to alterations in the structure and function of the genito-urinary 
system in old age. The senile changes in the breasts have been 
referred to in Chapter XXVII, page 531. 

The Ovaries. — The ovaries are withered and have a cicatricial 
aspect, and finally shrivel to little knobs of connective tissue 
containing a few cysts in the outer portions where formerly was 
the cortical zone. Ovarian tumors not infrequently develop in 
old age and cases have been reported by many observers where 
cystomata developed after the age of sixty, notably those re- 
ported by Johnson x who operated on a woman sixty-four years 
old, Davis 2 at the age of sixty-five, Spencer Wells 3 and J. Boeckel 4 
at seventy-three, Josephson 5 at seventy-six, F. Terrier 6 at sev- 
enty-seven, E. M. Owen 7 at eighty, and John Homans 8 at eighty- 
two years, four months. The last author (Three hundred and 
eighty-four laparotomies, 1887) in the course of two hundred 
and eighty-two ovariotomies, removed ovarian tumors from one 
woman aged seventy-two and three aged seventy-three years. 

The Fallopian Tubes. — The Fallopian tubes are deprived of their 
lining epithelium, they shrink in all their dimensions, finally the 
lumen is obliterated, and they become mere cords of connective 

1 Virginia Med. Monthly, 1888, Vol. XV., p. 644. 
■ 2 Brit. Med. Journ., 1887, Vol. II., p. 1050. 
3 "Tumours of the Ovary," 1888. 
4 Gaz. Med. de Strasbourg, 1896, p. 26. 
5 Centralblatt fur Gyn., 1889, No. 47, p. 824. 
6 Progres Med., 1888, No. 24, p. 466. 
7 Brit. Med. Journ., 1888, Vol. IX., p. 38. 
8 N. Y. Med. Rec, May 5, 1888, p. 496. 



624 THE MENOPAUSE AND OLD AGE 

tissue. Diseases of the tubes are extremely rare in old age. Chron- 
ically inflamed tubes necessarily can not undergo the retrograde 
changes as readily as healthy tubes. But, as a matter of clinical 
observation, diseased tubes generally cause symptoms during the 
childbearing period of life, exceptionally during the menopause, 
and almost never in old age. 

The Uterus. — The uterus becomes lessened both in volume and 
in weight as a result of retrograde changes in its structure and only 
when chronic metritis during menstrual life has converted the 
muscular structure of the organ into connective tissue and elastic 
tissue is its volume greater than normal. Aran found that after 
seventy years the uterus diminished in length from 2| inches (68 
millimeters) to 2 J- inches (57 millimeters) and in thickness from 
1-J--J- inches (43 millimeters) to 1 t 9 -q inches (40 millimeters). According 
to his observation the weight of the organ diminished in the case of 
the virgin uterus from 45 grammes to 35 grammes, and in the case of 
the parous uterus from 70 grammes to 60 grammes. Ordinarily this 
amount of diminution' both in dimensions and in weight is rather 
below the normal, and other observers, notably Arnal (Weinberg 
and Arnal, Mem. Soc. Anatom., May, 1905), who found a senile 
uterus which weighed 11.5 grammes, have reported finding a 
smaller organ after atrophic changes are well advanced. The 
walls of the uterus are diminished in thickness and the cavity is 
reduced in all its dimensions. The cervix generally, unless hin- 
dered by lacerations and thickenings, withers more than the body 
of the uterus. The internal os of the senile uterus is commonly 
found closed, probably because of the disproportionate atrophy of 
the cervix, the os being stenosed either by a thin diaphragm or by 
the formation of a ring of sclerotic tissue formed in this situation. 
Guy on (Thesis, Paris, 1858) found the os closed in thirteen out of 
twenty cases he observed, and Arnal (loc. cit.) found obliteration 
in sixteen cases and a partial stricture in five out of forty-one cases. 
Occasionally the external os is found closed also. If the cervical 
canal is closed the uterus generally contains a variable quantity 
of mucus. I have known of two cases, neither of them due to cancer, 
in which the uterine cavity was converted into an abscess cavity. 
As a rule the atrophic uterine mucosa of the senile uterus is covered 
with a thick, yellowish-white mucus. The mucous membrane is 
thinned and contains in its structure, often, hemorrhagic areas or 



OLD AGE 625 

small cysts, and its surface is wrinkled so that the appearance of 
hypertrophy is given to it. 

Senile endometritis, which is sometimes present, has been de- 
scribed in Chapter XI., p. 183. 

Cancer originates in the senile uterus, — more frequently cancer 
of the body, and less frequently cancer of the cervix, — the latter 
being a disease rather of the menopause. Any bloody vaginal 
discharge or a watery leucorrhea in an old woman should arouse 
the suspicion of cancer in the mind of the practitioner, and should 
lead to a thorough local examination. 

The Vagina. — The vagina, as was pointed out in the section of 
this chapter on the menopause, undergoes certain changes at the 
menopause which persist in old age, becoming more marked after 
the latter period of life is well advanced. The vagina is shortened, 
cone-shaped because of excessive atrophy in its upper portion, 
its walls are thinned and non-elastic. Later in life the diminution 
in caliber may be so great as to make coitus impossible. The 
atrophied, thinned mucosa may be the seat of inflammation. 
Senile vaginitis, which is described in Chapter XX., p. 365, is a very 
common affection and often results in adhesions. The symptoms 
consisting of a burning sensation in the vagina, dyspareunia, a 
feeling of weight in the pelvis accompanying a thin irritating leu- 
corrhea, are not characteristic. The diagnosis is made by a local 
examination. 

The Vulva. — The vulva shows signs of marked atrophy in old 
age. The hair of the mons veneris and labia majora becomes 
gray and scanty. The fat under the mons and in the labia dis- 
appears gradually after the post-climacteric period of hypernu- 
trition has been passed, and the labia become flabby and wrinkled 
so that they no longer come? together firmly in the median line. 
Therefore the vulva gapes in varying degree's in different indi- 
viduals, and the openings of the vagina and urethra are not so well 
protected from infection as in the younger woman. The mucous 
membrane of the vestibule is glassy, thin and smooth, and may 
show areas of ecchymosis. 

Pruritus vulva? (see Chapter X., p. 160) is a common affection, 
so are various dermatoses of which eczema is the most common. 
Kraurosis vulvae may occur in the aged, and primary cancer has 
been found very rarely in the vulva at this time of life. [i] 

40 



INDEX 



Abdomen, auscultation of, 72 
cavity of, shape of, Fig. 86, 221 
division of, into quadrants and in- 
dication of bony landmarks, Fig. 
18, 65 
gauze records of, 74, Fig. 20, 75 
in late pregnancy, appearance of, 427 
inspection of, 64 
mensuration of, 74 

in case of ovarian tumors, 304 
organs of, origin of tumors in, Fig. 

129, 304 
palpation of, 68 
percussion of, 71 
skin of, appearances of, 66 
swelling of, in case records, 8 

in clinical history, 20 
walls of, fat in, differentiated from 
ovarian tumor, 310 
fibromyoma of rectus muscle in, 

310 
movements of, 66 
with ascites, cross-section of, dorsal 
position, Fig. 132, 310 
lateral position, Fig. 133, 311 
Abortion, diagnosis of, 436 

etiology and frequency of, 437 
inevitable, diagnosis of, 439 
oxytoxic drugs a cause of, 437 
partially or wholly completed, diag- 
nosis of, 440 
symptoms of, 438 
syphilis, a cause of, 437 
threatened, diagnosis of, 439 
varieties of, definitions of, 436 
Abscess, anal, 514 
submucous, 515 
appendiceal, differentiated from pel- 
vic cellutitis, 196 
ischio- rectal, 515 
mammary, 542 
pelvic, 193 

mapped out by bimanual touch, 42 



Abscesss, pelvi-rectal, 515 

psoas, differentiated from pelvic 

cellulitis, 196 
sub-mammary, 542 
sub-urethral, differentiated from cys- 
tocele, 368 
from dislocation of urethra, 447 

Absence of any organ (see organ speci- 
fied) 

Acetonemia, odor of breath in, 61 

Acetonuria, in extra-uterine preg- 
nancy, 353 

Acromegaly, attended by amenorrhea, 
419 

Actinomyces. See Salpingitis, acti- 
nomycotic 

Acute diseases, a cause of sterility, 151 

Address, in clinical history, 9 

Adhesions, a result of pelvic peritonitis, 
192 
and incarceration of ovarian tu- 
mors, 315 

Age, in clinical history, 9 

Alcoholism a cause of sterility, 151 

Alligator bladder forceps, Fig. 50, 105 
rectal forceps, Fig. 62, 125 

Amenorrhea, 139 

as a symptom of pregnancy, 419 
primary, 139 
secondary, 141 

Ammonia coefficient in vomiting of 
pregnancy, 435 

Ampulla of Fallopian tube, Fig. 116, 
285 

Anal canal, anatomy of, 122 

region, diagram of, Fig. 195, 515 

Anatomy of organ. See organ speci- 
fied 

Anemia, a cause of sterility, 151 
in fibroid tumors, 258, 261 

Anomalies. See organ affected 

Anteflexion. See Uterus, anteflexion of 

Anuria, 156 



627 



628 



INDEX 



Anus, abnormally small, 498 

abscess in, 514 

at third month of fetal life, Fig. 
157, 392 

canal of, Fig. 150, 373, Fig. 191, 495 

cast of, Fig. 192, 496 

cancer of, 526 

chancre of, 511, 512 

chancroids of, 511, 512 

condylomata lata of, 512 

development of, Figs. 158-162, 395 

eversion of, for inspection of hem- 
orrhoids, 502 

fissure of, 503 

gumma of, 512 

imperforate, 497, 561 

inspection of, 121 

lipoma of, 523 

mucous patches of, 511 

papilloma of, 522 

protrusion from, as a symptom, 158 

soft fibroma of, 523 

syphilis of, 510 

syphilitic ulcerations of, 512 

tuberculosis of, 513 

vaginalis, 393 
Anxiety, polyuria in, 485 
Appendicitis differentiated from sal- 
pingitis, 336 
Applicator, uterine, Fig. 37, 93 
Apprehension, a cause of polyuria, 485 
Arbor vitse of cervical canal, 204, 

209 
Areola, anatomy of, 421, 532 

primary, 421, 532 

secondary, 426, 535 
Arnal, views of, on diminution in size 

of uterus in old age, 624 
Arterial tension, high, in menopause, 

613 
Arteriosclerosis, nienorrhagia in, 136 
Ascites, abdomen of, seen in profile, 
Fig. 131, 307 

differentiation of, from fibroid, 263 
from ovarian cyst, 308 

encysted, 308 
Auscultation of abdomen, 72 

Backache, 18 
Bacteriuria in children, 579 



Ball, Sir Charles, case .of absence of 
rectum, 496 

Ballantyne and Thompson, cases of 
prolapse of uterus in infants, 562 

Ballottement, external, 429 
internal, 427 

Barker, Fordyce, cases of late child- 
bearing, 602 

Bartholinitis, 409 

Bartholin's glands, abscess of, 409, Fig. 
176, 411 
abscess of ducts of, Fig. 175, 410 
anatomy of, 391 
cancer of, 414 

collection of discharges from, 61 
cyst and abscess of, differential 

diagnosis of, 412 
cyst of, differentiated from entero- 
cele, 371 
differentiated from hernia, 413 
cyst of left, Fig. 174, 409 
cysts of, 408 
lurking places in, for infection, 180 

Baudelocque. See Pelvis, conjugate 
diameter of 
cases of regular menstruation dur- 
ing pregnancy, 469 

Baumgarten and Poffer on acetonuria 
in extra-uterine pregnancy, 353 

Bearing-down feeling, 19 

Bender, X., and Lardennois, G., ob- 
servations that fibroids may be in- 
vaded by cancer metastases, 255 

Berger, H., cases of melancholia at 
menopause, 615 

Bichat, observations on old age, 622 

Bimanual touch. See Touch, bi- 
manual; also Palpation, bimanual 

Bladder, absence of, 457 
adenoma of, 483 
anatomy of, 101 
anomalies of, 457 
base of, showing diverticula, Fig. 

185, 458 
calculus of, 462 

in children, 582 
cancer of, 483 

capacity of, measurement of, 109 
catheterization of, 108 
clonic spasm of, 109 



INDEX 



629 



Bladder, contracted, a cause of fre- 
quency of micturition, 154 

contraction of, 461 

development of, Fig. 71, 198, Figs. 
158-162, 395 

diseases of, 457 
in children, 578 

displacement of, downward, 461 
lateral, 462 
upward, 461 

distended, 459. See also Bladder, 
overdistended 
differentiated from large ovarian 

tumor, 314 
differentiated from small ovarian 
tumor, 300 

diverticulum from, 458 

double, 458 

eversion of, through urethra, 462 

exstrophy of, 459 

fibroma of, 483 

fistulse of, 474. See also Fistula 

foreign bodies in, 463 

functional disturbances of, 151, 484 

hernia of, 462 

hypertrophy of wall of, differen- 
tiated from cystocele, 368 

inflammation of, 465 

irritability of, 485 

landmarks in, 103 

loculate, 458 

myoma of, 483 

new growths of, 480 

normal, laid open from the front, Fig. 
51,106 

overdistended, incontinence in, 154 
shape of, Fig. 84a, 217 

papilloma of, 482, Fig. 190, 482 

primary tumor of, in children, 582 

removing urine from, by suction 
apparatus, Fig. 55, 113 

rupture of, 460 

in retroflexion and incarceration 
of pregnant uterus, 432 

sarcoma of, 484 

stammering of, 109, 465 

stone in, 462, Fig. 186, 463 
in children, 582 

tuberculosis of ureteral orifice in, 
Fig. 187, 469 



Bladder, vagina and rectum ballooned 
by air, in examination of, Fig. 54, 
112 
varicose veins of, 474 
varix of, 474, Fig. 188, 474 
wall of, drumming of, 465 

hypertrophy of, differentiated from 

cystocele, 368 
thickening of, a cause of stricture 
of ureter, 489 
Bladder phantom, Fig. 58, 118 
Bladder symptoms, 151, 484 
in case records, 7 
in clinical history, 20 
Bland-Sutton, case of frequent hot 
flashes in menopause, 613 
case of multiple seedling fibroids, 244, 

251 
on hydatid fremitus, 299 
on myomatous affection of Fallopian 

tubes, 338 
on ovariotomy performed on children, 
576 
Blood pressure in menopause, 613 
vessels, uterine and ovarian, Fig. 8, 
47 
Bloodgood, J. C, classification of 
diseases of the breast, 536 
on sarcoma of the breast, 549, 551 
Blum, case of three mammae, 538 
Boils of vulva, 407 

Bokai, case of ligation of clitoris, 575 
statistics of rectal prolapse in chil- 
dren, 584 
Boldt, H. J., views on severe grades of 

exfoliative cystitis, 468 
Bondi, J., on varieties of cysts of the 

labia minora, 413 
Bonney, C. W., cases of rupture of 

pyosalpinx, 333 
Borner, case of premature menopause, 
600 
case of unexplained flowing at meno- 
pause, 619 
case of prolapse in virgin at meno- 
pause, 620 
is ovulation abolished with cessation 
of menstruation? 599 
Bowels, in case records, 8 
in clinical history, 21 



630 



INDEX 



Bozeman dressing forceps, 83 
Bozeman-Fritsch uterine irrigator, Fig. 

35,92 
Brain, disease of, cause of incontinence 

of urine, 155 
Breast, absence of, 538 
adenocarcinoma of, 546 

with papilloma in the cysts, 546 
age changes of, 534 
anatomy of, 533 
areola of, anatomy of, 421, 532 

primary, in early pregnancy, 421 

secondary, 426, 535 
cancer of, 545 
cancer cysts of, 548 

differentiated from galactocele, 
548 
colloid adenocarcinoma of, 546 
colostrum in, 427 
comedo-adenocarcinoma of, 546 
cyst of, simple, 540 

differentiated from cancer cyst, 
541 
cystic adenocarcinoma of, 546 
development of, incomplete, 538 
diseases of, 531 

classification of, 536 
dissection of lower half of, showing 

milk ducts, Fig. 198, 534 
division of, into quadrants, Fig. 200, 

538 
enlarged glands in axilla, a sign of 

tumor or inflammation of, 553 
enlarged supraclavicular glands in 

late cancer of, 554 
fullness of, a symptom of pregnancy, 

420 
galactocele of, 539 

hypertrophy of, diffuse bilateral, 
540, Fig. 201,541 

in puberty, 535 

infantile, 539 

lactation, 535 

senile parenchymatous, 540 
in early pregnancy, 421 
in late pregnancy, 426 
infantile, 534 
inflammations of, 542 
lactation hypertrophy of, 535 
late cancer of, cachexia in, 554 



Breast, late cancer of, discharge from 
nipple in, 553 

enlarged supraclavicular glands in, 
554 

metastases to other organs in, 553 

signs of, 553 

skin metastases in, 553 

ulceration of skin in, 553 
lymphatic glands of axilla, enlarged 

in inflammation of, 553 
lymphatics of, Fig. 199, 535 
medullary carcinoma of, 546 
milk ducts of, 532 
neuralgia of, 539, 553 
nipple of, anatomy of, 532 

discharge from, in late cancer, 553 

discharge of blood from, 545, 546 

Paget 's disease of, 548 

retraction of, 553 
of puberty, 535 
pain in, 553 
phantom tumor of, 539 
rheumatism of pectoral muscle in, 

553 
right, vertical section of, Fig. 197, 

533 
sarcoma of, 549 

scirrhous cancer of, Fig. 202, 547 
scirrhous carcinoma of, 548 
senile, 536 

supernumerary mammae of, 538 
symptomatic lesions of, 539 
syphilis of, 544 
tumors of, age as affecting, 550 

diagnosis in general of, 549 

duration of, 551 

early diagnosis in, 549 

history as affecting diagnosis of, 550 

mobility of, 552 

rare forms of, 537 

situation of, 551 

varieties of: adenoma, cystic, 545 
adenofibroma, 544 
cancer, 545 

average duration of life in, 545 
fibro-epithelial, 544 
myxoma, intracanalicular, 544 
papilloma, intracystic, 545 
veins of, enlarged in early pregnancy, 

421 



INDEX 



631 



Brewer bivalve speculum, Fig. 26, 87 
Broad ligaments. See Ligaments, 

broad 
Burrage uterine speculum, Fig. 36, 93 

used in packing uterus, 96 

Cabot, A. T., case of horny-celled cys- 
titis, 470 
Calibrator, meatus, Kelly, Fig. 44, 101 
Campbell, R. P., on the diagnostic 
significance of spirochseta pallida, 407 
Canal, anal, Fig. 191,495 
Canavan, M. M., case of ulcerative 
vaginitis in bacillary dysentery, 364 
Cancer. See Organ affected 
Cancer and fibroids, to be excluded 
from statistics on the menopause, 
590 
Cantharides, a cause of cystitis, 467 
Capacity of bladder, 109 

of pelvic cavity, 98 
Carcinoma. See Cancer and organ 

affected 
Caruncle. See Urethra 
Carunculae myrtiformes, Fig. 165, 397 
Case-record system, 6 
Case-records, form for, 6 
Casper, on appearances of bladder by 

indirect cystoscopy, 117 
Catheter, bladder, long, Fig. 43, 101 

ureteral, Kelly, Fig. 48, 103 
Catheterization in children, 578 
of bladder, 108 
of ureters, 115 

caution against, 479 
Cauliflower growth. See Cervix, can- 
cer of 
Causation of disease in any organ. See 

organ affected 
Cellular tissue, pelvic, anatomy of, 192 
Cellulitis, pelvic, 192 
diagnosis of, 194 
differential diagnosis of, 195 
differentiated from appendiceal 
abscess, 196 
from pelvic hematocele, 196 
from pelvic peritonitis, 195 
from psoas abscess, 196 
from pyosalpinx, 196 
from subserous myoma, 196 



Cellulitis, etiology and pathology of, 
192 
symptoms of, 193 
Cervicitis. See Endocervicitis 
Cervix, adenocarcinoma of, diagnosis 
of, 275 
differential diagnosis of, 276 
adenocarcinoma of canal of, 268 

early stage of, Fig. Ill, 268 
anatomy of, 204 
appearance of, in early pregnancy, 

422 
atrophy of, at menopause, 594 
canal of, collection of discharges from, 

62 
cancer of, a cause of stricture of 
ureter, 489 
cauliflower growth, 271 
diagnosis of, 271 
differential diagnosis of, 272 
differentiated from erosion, 186 

from fibroid, 265 
early stage of, Fig. 110, 267 
infiltrating, 272 
squamous-celled, 267 

early stage of, Fig. 110, 267 
ulcerating, 272 
chancre of, differentiated from 

erosion, 186 
chancroids of, differentiated from 
cancer, 275 
from erosion, 186 
condylomata of, differentiated from 

cancer, 273 
elongation of, hypertrophic, Fig. 88a, 
225 
case of Huguier, 225 
differentiated from prolapse, 229 
false, 209 
erosions of, 184 

cause of sterility, 150 
differentiated from cancer, 274 
from cancerous ulceration, 186 
from chancre, 186 
from chancroid, 186 
from tuberculous ulcer, 186 
from ulceration, 186 
follicular, 185 
in children, 563 
papillary, 185 



G32 



INDEX 



Cervix, erosions of, purple m color in 
early pregnancy, 422 
simple, 184 
with lacerations, Fig. 69, 185 

fibroids of, 247 

follicles of, hypertrophied, differen- 
tiated from cancer, 273 

gumma of, differentiated from cancer, 
275 

hypertrophic elongation of, true, 225, 
229 

inflammatory thickening of, differen- 
tiated from cancer, 273 

lacerated, a cause of hemorrhage at 
menopause, 618 

lacerations of, 204 

a cause of sterility, 150, 151 
bilateral, Fig. 79, 205 

with eversion of lips, Fig. 82, 208 
crescentic, Fig. 81, 207 
differential diagnosis of, 210 
etiology of, 204 

mechanism of production of, 205 
old, 209 
recent, 208 
results of, 206 
stellate, Fig. 80, 206 
unilateral, Fig. 83, 209 

mucous polypi of, differentiated 
from cancer, 273 

myoma of, differentiated from can- 
cer, 273 

of purplish color in early pregnancy, 
422 

papillary tuberculosis of, differen- 
tiated from cancer, 273 

removal of tissue from, for examina- 
tion, 62 

sarcoma of, 280 

syphilis of, differentiated from can- 
cer, 275 

tuberculosis of, differentiated from 
cancer, 273 

ulcer of, from papule, differentiated 
from cancer, 275 
simple, differentiated from cancer, 
274 
from erosion, 186 
tuberculous, differentiated from 
cancer, 274 



Cervix, tuberculous, differentiated from 
erosion, 186 

Chancre. See Vulva, Vagina, Cervix, 
Anus, and Urethra, chancre of 

Chancroids. See Vulva, Vagina, Cer- 
vix, and Anus, chancroids of 

Change of life. See Menopause 

Chiene, ovariotomy on three-months- 
old child, 293 

Child, new-born, longitudinal median 
section of, Fig. 204, 558 

Childbearing, in case records, 7 
late, 601 

Childhood, gynecological affections of, 
555 

Children, examination of, 556 
number of, in clinical history, 11 

Chlorosis, amenorrhea a symptom of, 
419 

Cholemia, menorrhagia in, 135 

Chorioepithelioma. See Uterus, Vagi- 
na, and Tube, Fallopian 

Chromocystoscopy, 119 

Chute, A. L., case of infected diverticu- 
lum of bladder, 458 

Claisse, A., theory as to etiology of 
fibroids, 250 

Cleanliness in vaginal examinations, 28 

Climacteric. See Menopause 

Clitoris, Fig. 156, 389 
anatomy of, 390 
at third month of fetal life, Fig. 157, 

392 
malformations of, 393 
prepuce of, adherent, 557 

Cloaca, Fig. 159, 395 

Clothing, loosening of, as preparation 
for examination, 24 

Clover crutch leg-holders, 57 

Coccygodynia, 159 
in clinical history, 19 

Coccyx, pain in, 159 

Coitus, barred by vaginismus, 379 
excessive, a cause of abortion, 437 
of cystitis, 467 
of sterility, 151 
injuries of hymen due to, 401 

of vagina due to, 376 
painful, 146 
through dilated urethra, 444 



INDEX 



633 



Coitus, unnatural, a cause of gonor- 
rheal proctitis, 510 

Collection of tissues and discharges, 
61 

Colostrum. See Breast 

Colpitis, 361 

Combined vagino-abdominal touch, 38 

Comby, J., on vulvar hemorrhages in 
little girls, 572 

Complaint, chief, in clinical history, 7, 
12 

Conception, factors essential for, 149 
late in life, 601 
without sexual feeling, 149 

Condylomata, acuminata and lata. 
See Vulva and Anus 

Congenital anomalies and malforma- 
tions. See organ affected, anom- 
alies and malformations of 

Congestion, pelvic, a cause of leucor- 
rhea, 145 
of menorrhagia, 135 
of sterility, 151 

Conjugate diameter of pelvis, 96 

Constipation, a cause of fissure in ano, 
503 
of hemorrhoids, 500 
of retroversion, 236 
in clinical history, 21 

Controller, current, Fig. 57, 117 

Cord, spinal, diseases of, retention and 
incontinence of urine in, 485 

Corpus luteum. See Ovary 

Craig, M., views on mental disease at 
menopause, 615 

Cryptomenorrhea, 139, 140 

Cullen, T. S., on adenomyoma of 
uterus, 245 

Cullingworth on hemorrhage in the 
new-born, 572 

Cultures, method of taking, 62 

Current controller, Fig. 57, 117 

Curette, uterine, Fig. 31, 90 
forceps, Emmet, Fig. 30, 89 

Curetting, dangers of, 93 
technique of, 90 

Currier, A., on the menopause among 
American Indians, 588, 598 

Cylinder, vertical, likened to cavity of 
abdomen, Fig. 7, 45 



Cyst. See Ovary, Vagina, and Paro- 
varium, cyst of 

tubo-ovarian, 334 
Cystitis, 465 

a cause of dysuria, 153 

catarrhal, 467 

chronic, hypertrophy of bladder wall 
in, differentiated from cystocele, 
368 

classification of, 466 

cystoscopy in, 473 

diagnosis of, 471 

etiology and pathology of, 466 

examination of urine in, 471 

exfoliative, 468 

in children, 581 

palpation of bladder in, 472 

symptoms of, 471 

tuberculous, 468 

ulcerative, 468 

vesicular, 470 

with cornified patches, 470 

with yellowish plaques, 471 
Cystocele, Fig. 148, 366, 367 

at menopause, 621 

diagram of, Fig. 148a, 368 

differential diagnosis of, 367 
Cystoscope, bladder, Kelly, Fig. 49, 104 

ureter, Nitze, Fig. 56, 116 
Cystoscopy, direct, 110 

electric, 117 

indirect, 117 

instruments used in, 99 

removing urine from bladder by 
suction in, Fig. 55, 113 

D alton, J. C, case of absence of corpora 

lutea in degenerated ovaries, 593 
Davies, J., case of late child-bearing, 

602 
Davis, L., analysis of forty-five cases of 

bladder tumor, 481 
Decidua, uterine, in extra-uterine 

pregnancy, Fig. 143, 344, 345 
Defecation, difficulty in, as a symptom, 

158 
Deformed pelvis, 95 
Delayed menopause, 601 
Demme-Granicher, case of fibrosarcoma 

of vagina in a child, 570 



634 



INDEX 



Depressor, Hunter, Fig. 29, 88 
Diabetes, urine of, a cause of pruritus, 

160 
Diagnosis of disease in any organ. 

See organ affected and disease af- 
fecting 
Diameters of pelvis, 96 
Diarrhea in rectal disease, 158 
Digital examination of rectum, 123 

of vagina, 34 
Digital exploration of uterine cavity, 

94 
Dilatation of uterus, 91 
Dilator, urethral, double-ended, Fig. 
45, 102 

uterine, Hanks, Fig. 33, 91 
Wathen, Fig. 34, 92 
Discharge, rectal, 157 

in hypertrophic proctitis, 509 

vaginal. See Leucorrhea 
in case records, 7 
in clinical history, 18 
Diseases, constitutional, causing amen- 
orrhea, 141 
Doderlein, lactic acid, bacterium of, 

355 
"Dodging time" of menopause, 611 
Dressing forceps, uterine. See Forceps 
Drumming of bladder, 109, 465 
Ducts, milk. See Breast 

of Miiller, 197, Fig. 71, 198 
Dudley, E. C, tables of differential 

diagnoses, 195-196, 308-309 
Dysmenorrhea, 128 

associated with pelvic lesions, 129 

differentiated from abortion, 441 

due to poor health, 130 

membranous, 131, 172 

neurotic, 130 

obstructive, 129 

with fibroids, 129 

with malformation of uterine organs, 
129 

with no pelvic lesion, 130 

with pelvic inflammation, 129 

with retroposition and anteflexion, 
129 
Dyspareunia, 146 

in clinical history, 11 
Dysuria. 151 



Ears, ringing in, in menopause, 613 
Echinococcus cyst, differentiated from 
large ovarian tumor, 314 
from small ovarian tumor, 299 
Ectopic pregnancy and chorioepithe- 
lioma. See Pregnancy, extra-uterine, 
and Chorioepithelioma, ectopic 
Edebohls vaginal speculum, Fig. 32, 

91 
Edgar, J. C, on frequency of abortion, 

437 
Edwards, W. A., views on adherent 
prepuce in the child, 557 
on malignant disease of the uterus 

and ovaries in children, 278, 576 
on masturbation, 575 
Elevated pelvis position, 58 
Emmet, T. A., views on dilatation of 
urethra, 448 
on laceration of the cervix, 204, 207, 

209 
on pelvic circulation, 48 
on vesico-utero-vaginal fistula, 479 
on vesico- vaginal fistula, 475 
Emmet curette forceps, 89 
Endocervicitis, 184 
definition of, 165 
Endometritis, a cause of hemorrhage at 
menopause, 618 
of sterility, 150, 151 
acute septic, 174 
acute simple, 173 
anatomico-pathological classification 

of 171 
atrophic, 171 
chronic simple, 176 
decidual, differentiated from mem- 
branous dysmenorrhea, 131 
definition of, 165 
exfoliative, 172 
fungous, 171 
glandular, 171 
gonorrheal, 179 
acute, 180 
chronic, 182 
hyperplastic, 170 
hypertrophic, 170 
in old women, 183 
interstitial, 171 
not preceded by an acute stage, 177 



INDEX 



635 



Endometritis, polypoid, 172 
post-abortum, 176 
pseudodiphtheritic, 172 
senile, 183 
tuberculous, 173 

Endometrium, anatomy of. 166 
before puberty, 168 
decidual modification of, Fig. 146, 

352 
during pregnancy. 169 
following menopause, 169 
normal, Fig. 65, 167 
pathology of, 169 

Endoscopy, direct, 110 

Enterocele of vagina, 371 

Enteroptosis, 67 

body pose in. Fig. 19, 67 

Enuresis, 154 
in children. 578 

Epilepsy, incontinence of urine in, 485 

Epispadias, 393, 445. 459 

Epstein on vulvo-vaginitis in children, 
566 

Erosion of cervix. See Cervix, erosion 
of 

Escherich, on bladder affections in 
children. 579. 581 

Etiology of disease in any organ. See 
organ affected 

Evacuator. bladder, Kelly, Fig. 46, 102 

Examination, positions for. See Po- 
sitions 

Exanthemata, menorrhagia in, 135 

Excision of tissue for microscopic ex- 
amination, 62 

Exploration of uterine cavity, digital, 
94 

External genitals. See Genitals, ex- 
ternal 

Extra-uterine pregnancy. See Preg- 
nancy, extra-uterine 

Exudate, pelvic. See Inflammation, 
pelvic 

I'ai-.kicius, case of myoma of vagina, 

381 
Face, aspect of, in pregnancy, 420 
Fades ovarina. 29 4. 295, 302 
Fallopian tube. See Tube, Fallopian 
Family history. See History, family 



Fecal accumulation, differential diag- 
nosis of, from ovarian tumor, 309 
Feces, character of, as a symptom of 
rectal disease, 158 
incontinence of, in children, 585 
Fen wick, E. Ft., on villus- covered and 

bald bladder tumors, 481 
Ferguson cylindrical speculum, 86 
Fetus, mummified, 345 
Fibro-cystic tumors of uterus, 253 
Fibroids. See Uterus, fibroids of 
Fibroma. See Uterus, fibroids of; 

also Ovary, fibroma of 
Fibromyoma of rectus muscle, 310 
Figure, the, in late pregnancy, 426 
Fimbriated extremity of tube, Fig. 116, 

285 
Finger, examining, points noted by, 36, 
40 
introduction of, into vagina, 35 
used as speculum, 36 
Fischel, on erosions of cervix in chil- 
dren, 563 
Fissure in ano, 503, Fig. 194, 504 
diagnosis of, 504 
differential diagnosis of, 505 
in children, 585 
symptoms of, 503 
syphilitic, differentiated from fissure 
in ano, 505 
Fistula, between bladder and extra- 
uterine fetation sac, 480 
between bladder and ovarian cyst, 

480 
between bladder and pelvic ab- 
scess, 480 
blind internal differentiated from 

fissure in ano, 505 
entero-vaginal, 387 
in ano, 516 

complete, 516, Fig. 196, 517 
diagnosis of, 518 
blind external, 517 
blind internal, 517, Fig. 196a, 517 
symptoms of, 518 
recto-vaginal, 386 
recto-vesical. 480 
uretero-intestinal, 493 
uretero-uterine, 492 
uretero-vaginal, 386, 492 



636 



INDEX 



Fistula, uretero-vaginal, differentiated 
from vesicovaginal fistula, 478 
ureterovesical, 492 
urethro vaginal, 386 
vesicointestinal, 479 
vesico-uterine, 479 

differentiated from vesico- vaginal 
fistula, 479 
vesico-utero-vaginal, 479 
vesico- vaginal, 384, 474 
diagnosis of, 477 

frequency, etiology, and pathol- 
ogy of, 474 
symptoms of, 476 
Fistulse, genital, diagrammatic repre- 
sentation of, Fig. 189, 476 
scheme of, Fig., 155, 385 
ureteral, 492 
vesical, 474 
Flashes or flushes, hot, 612 
Floor, pelvic. See Pelvis, floor of 
Flowing. See Hemorrhage 
Forceps, bladder, alligator, Fig. 50, 105 
Emmet curette, Fig. 30, 89 
rectal, long alligator, Fig. 62, 125 
tenaculum, double, 85 
uterine dressing, Fig. 23, 83 
vulsellum, Fig. 25, 85 
Foreign bodies in any organ. See 

organ affected 
Fourchette, Fig. 156, 389 
Fowler, case of incontinence of feces 

in a girl of thirteen, 585 
Frankel, function of the corpus luteum, 

13 
Friedlander, C, doubtful case of pri- 
mary tuberculosis of vagina, 365 

Gait, the, in late pregnancy, 426 

Galactocele, 539 

Garceau, cases of primary ureteral 
tumors, 493 

Garre, case of five mammae, 538 

Gartner's duct, cyst of, Fig. 154, 381 
diagram of, Fig. 120, 290 

Gautier, V., cases of precocious men- 
struation and precocious maturity, 
564 

Gee, on hematuria a sign of infantile 
scurvy, 583 



Gellhorn, G., on development of hy- 
men, 396 
General appearance, in case records, 8 
General health, in case records, 8 
General paralysis, retention and in- 
continence of urine in, 485 
Genital fold, Fig. 157, 392 
Genital hemorrhage in the child, 571 
Genital organs, development of, Figs. 
158-162, 395 
external, at beginning of third 
month, Fig. 157, 392 
atrophic changes in, at menopause, 

595 
development of, 392 
inspection of, 33 
Genital ridge, Fig. 157, 392 
Gierke, cases of cystitis with yellowish 
plaques, 471 
on noma of the vulva, 570 
Girls, little, vulvar hemorrhages in, 572 

young, examination of, 25 
Glands, Bartholin's, abscess of, 409, 
Fig. 176, 411 
abscess of ducts of, Fig. 175, 410 
anatomy of, 391 
cancer of, 414 

collection of discharges from, 61 
cyst of left, Fig. 174, 409 
cysts of, 408 

differentiated from enterocele, 

371 
from hernia, 413 
differential diagnosis of cyst and 

abscess of, 412 
lurking-places for infection, 180 
Lushka's coccygeal, 159 
lymphatic, of breast, 533 

enlarged in cancer, 553 
mammary. See Breast 
Skene's, anatomy of, 101 

collection of discharges from, 61 
lurking-places for infection, 180 
thyroid, function of, 593 
Gonococcus, characteristics of, 179 
in cervical canal in children, 577 
infection, 179 
Gonorrhea, 179. See also organ affected 
history of, caution in procuring, 183 
latent, in women, 182 



INDEX 



637 



Gonorrhea, latent, lurking-places for 

gonococcus in, 452 
Goodsall and Miles, analysis of symp- 
tom of cancer of rectum, 527 
enumeration of abscesses in anal 

region, 515 
on fistulse originating posterior to 
anus, 518 
Graafian follicles, degenerated after 
infectious diseases, 577 
enlarged, 290 
Graves bivalve speculum, Fig. 27, 87 
Gross, S. D., statistics of sarcoma of 

breast, 551 
Growth, failure of, a cause of amen- 
orrhea, 139 
Gumma. See organ affected 
Gusserow, fatty degeneration of fi- 
broids, 253 
percentages of ages at which fibroids 
occur, 249 
Guy on, observations on closure of os 
uteri in old age, 624 

Hand, examining, showing protective 

sleeve, Fig. 2, 31 
Hanks uterine dilator, Fig. 33, 91 
Hann, R. G., case of late child-bearing, 
603 
case of recurrence of sexual feeling at 
forty-nine, 614 
Hare, F., case of inhalation of amyl 

nitrite stopping menstruation, 596 
Hart and Barbour, views on pelvic 

floor, 220 
Heart disease, a cause of hemorrhoids, 
500 
of pelvic congestion, 467 
menorrhagia in, 135 
Heart sounds, fetal, auscultation of, 429 
Hegar, view that tubes, uterus, and 
vagina form a duct for the gland, the 
ovary, 593 
Hegar's sign, 425 

bimanual palpation for, Fig. 179, 425 
Hematocele, pelvic, Fig. 142, 343, 347 
differentiated from pelvic cellulitis, 
196 
Hematocolpos, Fig. 171, 360 
Hematoma of ovary, 346 



Hematoma of vagina, 377 

of vulva, 400 
Hematometra, 360, Fig. 172, 398 
Hematosalpinx, 334, 360, Fig. 139. 
335 
danger of rupturing, 398 
diagram of, Fig. 173, 399 
differentiated from small ovarian 
tumor, 298 
Hematuria, a sign of papilloma of 
bladder, 483 
a symptom of ureteral tumors, 493 
in children, 583 
Hemophilia, in children, 571 

menorrhagia in, 135 
Hemorrhage, at menopause, 617 
of unexplained causation, 619 
following curetting, 94 
from anus, in hemorrhoids, 502 
genital, in the child, 571 
in fibroid tumors, 260 
uterine. See Menorrhagia and Met- 
rorrhagia 
Hemorrhoids (or piles), 498 
external, 500 

inflamed, with erosion, Fig. 193, 

499 
not to be pushed into anus or 
squeezed, 501 
frequency and etiology of, 498 
internal, 501 

hemorrhage as a symptom of, 157, 

502 
prolapsed, Fig. 193, 499 
with edema of anal margin, Fig. 
193, 499 
mucoid discharge in, 502 
thrombotic, Fig. 193, 499 
types of, Fig. 193, 499 
Hermaphroditism, 399 
false, female, 400 

male, 400 
true, 399 
Hernia, anterior, into vagina, 368 
inguinal, in labium majus, 412 

differentiated from rectocele. 37 1 
intestinal, into vagina^ differentiated 

from cystocele, 368 
labial, 412 

in the child, 558 



638 



INDEX 



Hernia, vulvar, differentiated from 

rectocele, 371 
Heubner, on masturbation, 575 

on vulvo- vaginitis in children, 567 
Hilton's white line, Fig. 191, 495 
Hind-gut, arrested development of, 496 

development of, Fig. 158, 395 
Hirst, B. C, cases of operations on 
pregnant women by mistake, 418 

cases of ovarian tumor in upper ab- 
domen, 302 
History, family, 7, 12 

method of getting, 5 

previous, 7, 12 
Hitschmann and Adler's views on en- 
dometritis hypertrophica, 171 

on the endometrium, 168 
Holt, L. Emmett, on masturbation, 575 

on vulvo-vaginitis in children, 567 
Horizontal section of uterus, Fig. 67, 

171 
Hot flashes in menopause, 612 
"Hottentot apron," 394 
Hours, P., on metrorrhagia of puberty, 

573 
Houston, valves of, 122 
Huguier, case of true hypertrophic 
elongation of cervix, 225 

cases of abscess of duct of Bartho- 
lin's gland, 410 
Hunner, G., technique of finding tu- 
bercle bacilli in urine, 469 
Hunter vaginal depressor, 89 
Hurdon, E., cases of papilloma of 
Fallopian tube, 337 

views on sarcoma of uterus, 278 
Hiisler, G., on primary tumors of blad- 
der in children, 582 
Hydatid disease. See Echinococcus 
"Hydatid fremitus," 299 
Hydatid of Morgagni, 327 
Hydatidiform mole, 441, Fig. 182, 442 

diagnosis of, 443 

pathology of, 441 

symptoms of, 443 
Hydrocele of canal of Nuck, 213 
Hydrosalpinx, 333, Fig. 138. 33 1 

differentiated from small ovarian 
tumor, 298 

follicular. 334 



Hydrosalpinx, intermittent, 334 

Hydrup-Pederson, case of atresia of 
vagina in child following diphtheria, 
569 

Hymen, Fig. 156, 389 
anatomy of, 390 
atresia of, a cause of amenorrhea, 

140 
development of, Fig, 162, 395 
different forms of, Figs. 163-170, 397 
imperforate, 396 

in the child, 560 
malformations of, 396 
rigid, a cause of sterility, 150 
with pin-head opening, 396 

Hyperemesis gravidarum, 434 

Hypernephroma differentiated from 
ovarian tumor, 313 

Hypophysis cerebri, tumors of, at- 
tended by amenorrhea, 419 

Hypospadias, 393, 444 

Hysteria, anuria in, 156 
polyuria in, 485 

Illness, present, in clinical history, 22 
Imperforate anus, 497 

rectum, 496 
Inbreeding, a cause of sterility, 151 
Incarceration of ovarian tumors, 315 
Incontinence of feces in children, 585 

of urine, 154, 485 
Infancy, gynecological affections of, 555 
Infant at birth, uterine organs of, seen 

from above, Fig. 205, 562 
Infantile uterus, 140, 202, Fig. 117, 286 

vulva, Fig. 203, 556 
Infectious diseases, menorrhagia in, 135 
Inflammation, pelvic, 187 
a cause of cystitis, 467 
causing fixation of uterus in pro- 
lapse, 223 
differential diagnosis of (table), 195 
dysmenorrhea in, 129 
exudate in, differentiated from 
cancer, 277 
from fibroid, 263 
routes of infection in, 187 
Injuries of. See Vulva, Vagina, Ure- 
thra, Bladder, injuries of 
Insemination without penetration, 149 



INDEX 



639 



Introitus vaginae, Fig. 156, 389 
Instruments, care of, before and after 
use, 30 

for examination, list of, 28 

in diagnosis, 77 
Intercourse, sexual. See Coitus 
Intermenstrual pain, 132 
Intestines, gas or fecal matter in, 

differentiated from large ovarian 

tumor, 309 
Intra-abdominal pressure, variations 

in, 224 
Irrigator, uterine, Bozeman-Fritsch, 

Fig. 35, 92 
Irritable bladder, 485 
Ischuria, 155 
Isthmus of Fallopian tube, Fig. 116, 

285 
Itching. See Pruritus 

at anus after going to bed, a symptom 
of piles or eczema, 157 

of vulva, 160 

Jacobi, M. P., on menstrual wave 

theoiy, 595 
Jacquemin's sign, 422 
Jaundice, menorrhagia in, 135 
Jet of urine from ureteral orifice, Fig. 

52, 107 
Johnson, F. W., case of fibromyoma of 

rectus, 310 
Jung, on gonococcus in cervical canal 

in children, 577 

Kakels, S. W., on vulvo- vaginitis in 

children, 567 
Kehrer, E., cases of pregnancy in rudi- 
mentary cornua, 433 
Kelly and Cullen, on myomata of 
uterus, 249, 258, 261 
on myoma of vagina, 381 
Kelly, H. A., case of fibroid that had 
developed while under observa- 
tion, 251 
cases of imperforate hymen following 

typhoid fever, 560 
method of injecting kidney to pro- 
duce renal colic, 312 
pus cells in urine of cystitis con- 
verted into mucus in presence of 
proteus infection, 472 



Kelly cystoscope, Fig. 49, 104 

double-ended urethral dilator, Fig. 

45, 102 
evacuator, Fig. 46, 102 
meatus calibrator, Fig. 44, 101 
ureteral catheter, Fig. 48, 103 
ureteral searcher, Fig. 47, 102 
wash-bottle suction apparatus in use, 
Fig. 55, 113 
Kennedy, W. J., case of late child- 
bearing, 602 
Kerley, on causes of enuresis, 579 
Kidney, ache in, a sign of papilloma of 
bladder, 483 
echinococcus cyst of, differentiated 

from ovarian tumor, 313 
movable, differentiated from ovarian 
tumor, 313 
palpation of, 70, 71 
polycystic disease of, differentiated 

from ovarian tumor, 313 
simple cysts of, differentiated from 

ovarian tumor, 313 
tumors of, differentiated from ova- 
rian tumor, 313 
Kisch, cases of prolonged menstrua- 
tion, 603 
table of gynecological affections 
found during menopause, 589 
Knee-chest position, 56, Fig. 13, 56 
modified for cystoscopy, Fig. 53, 111 
side view of, Fig. 14, 57 
Kobelt's tubules, diagram of, Fig. 120, 

290 
Kraurosis vulvas, 404 
Krieger, E., statistics as to age of the 
menopause, 597 

Labia majora, anatomy of, 388 

malformations of, 394 
Labia minora, adherent, 394 

anatomy of, 390 

cysts of, 413 

malformations of, 394 
Labium ma jus, Fig. 156, 389 

hematoma of, 400 
. hydrocele of, in the child, 559 

tumor of, differentiated from entero- 
cele, 371 
from hernia, 413 



640 



INDEX 



Labium minus, Fig. 156, 389 
Labor, premature, definition of, 436 
Laceration of cervix. See Cervix, 

laceration of 
Laceration of perineum. See Peri- 
neum, laceration of 
Lactation, a cause of amenorrhea, 141 

prolonged amenorrhea a symptom 
in, 419 
Lactation atrophy of uterus, 203 
Lactation hypertrophy. (See Breast) 
Latent gonorrhea, 182 
Latent seedling fibroids, 251 
Leg holders, 57 

Leopold, on erosion of cervix in chil- 
dren, 563 
Leucorrhea, 143, 355 

a cause of pruritus, 160 

a symptom of endocervicitis, 185 
of endometritis, 177 
of pregnancy, 420 

bloody discharge in, 144 

"currant juice," in hydatidiform 
mole, 443 

fetid discharge in, 144 

in case records, 7 

in children, 144 

in clinical history, 18 

in fibroid tumors, 261 

in married women, 145 

in old women, 146 

in virgins, 145 

normal vaginal discharge and, 355 

watery discharge in, 144 

white discharge in, 143 

yellow discharge in, 143 
Leukemia, menorrhagia in, 135 
Levator ani muscle, Fig. 150, 373, Fig. 

151, 374, Fig. 152, 375 
Ligament, infundibulo-pelvic, Fig. 116, 
285 

of ovary, Fig. 116, 285 
Ligaments, broad, attachments of, 44 
diseases of, 211 
varicocele of, 212 

round, attachments of, 45 
diseases of, 212 
hydrocele of, 213 
tumors of, 212 

Uterine, anatomy of, 44 



Ligaments, uterine, diseases of, 210 
mechanics of, 222 
utero-ovarian, 214 
utero-sacral, 213 
attachments of, 44 
course of, in intraligamentous 
tumor, Fig. 135, 317 
in retroperitoneal tumor, Fig. 
134,316 
Light for cystoscopy, varieties of, 111 
Linea alba, pigmentation of, 67, 427 
Linea nigra, 67, 427 
Lineae albicantes, 67 
Lithopedion, 345 
Lithotomy position, 57 
Liver, cirrhosis of, a cause of pelvic 
congestion, 467 
tumors of, differential diagnosis of, 
from ovarian tumors, 312 
Locomotor ataxia, incontinence of 

urine in, 155, 485 
Long female catheter, Fig. 43, 101 
Lubricant for vaginal examination, 35 
Lund, F. B., ovariotomy on three- 
months-old child, 294 
Luys urine separator, Fig. 59, 119 

McBurney's Point, 337 

McCosh, A. J., case of early carcinoma 

of breast, 550 
McDonald, E., on rhythmical con- 
tractions of pregnant uterus, 424 
Macula gonorrhoica, 411 
Mamma. See Breast 
Marchand, F., on chorioepithelioma, 280 
on pathology of hydatidiform mole, 
541 
Mastitis, acute, 542 

carcinomatous, 543 
chronic, 543 

actinomycotic, 544 
interstitial, 543 
lobular, 543 
syphilitic, 544 
tuberculous, 543 
Mastodynia, 553, 539 
Masturbation, 574 

a cause of leucorrhea, 144 
of sterility, 151 
of vaginismus, 379 



INDEX 



641 



Masturbation, and pruritus, 161 

breast changes in, similar to preg- 
nancy, 421 
Maturity, precocious, 564 
case of, Fig. 207, 565 
Meatus calibrator, Kelly's, Fig. 44, 101 
Meatus urinarius, Fig. 156, 389 
Memory, loss of, in menopause, 613 
Menopause, 587 

age of occurrence of, 597 

atrophic changes in, 17 

blood pressure in, 613 

delayed, 601 

delusional insanity in, 615 

displacements of uterus at, 620 

dodging time of, 611 

duration of, 611 

dyspepsia in, 615 

eczema vulvae at, 621 

gastritis, atonic, in, 615 

gastro-enteritis in, 616 

hemorrhages of, 617 

heredity as affecting, 598 

high arterial tension in, 613 

hot flashes in, 612 

hyperchlorhydria in, 615 

in clinical history, 16 

influence of race and locality on, 597 

injuries of vagina after, 621 

insomnia in, 613 

intercostal neuralgia in, 663 

irritability of temper in, 613 

loss of memory in, 613 

melancholia in, 615 

mental diseases at, 615 

nervous system in, 613 

neurasthenia in, 614 

nutrition in, 616 

obesity at, 616 

phenomena of body and mind in, 612 

premature, 598 

associated with obesity, 599 

pruritus vulvae at, 161, 621 

psychoses in, 615 

pulse rate in, 613 

rheumatism in, 616 

sexual feeling in, 614 

skin diseases in, 617 

tables of 115 cases of, 604 

tachycardia in, 613 
41 



Menopause, vesical symptoms at, 621 
Menorrhagia, 134 

constitutional causes of, 135 

differentiation of, from abortion, 441 
Menorrhagia and metrorrhagia, differ- 
entiated from abortion, 441 

in married women, 139 

in nulliparae, 137 

in parous women, 138 

in pregnancy, 138 

in virgins, 137 

local causes of, 135 
Menstrual period, a predisposing cause 

of cystitis, 467 
Menstruation, date of beginning of 
last, 8 

delayed, and pelvic disease, 15 

description of, 13 

during pregnancy, 419 

in case record, 7 

molimen of, 128 

physiology of, 595 

precocious, 564 

prolonged, 603 

vital energy, wave of, governing, 595 

wave theory concerning, 595 
Mensuration of abdomen, 74 
Mental disease at menopause, 615 

overwork, a cause of amenorrhea, 142 
Metritis, 165 

chronic, a cause of hemorrhage at 
menopause, 618 
Metrorrhagia, 134 

after menopause a sign of cancer, 138 

coming on six weeks after labor may 
mean chorioepithelioma, 138 

differentiated from abortion, 441 

may mean extra-uterine pregnancy, 
138 

may mean uterine polyp, 138 
Michaelis' rhomboid, 96 
Micturition, frequent, 153 

a symptom of pregnancy, 420 

painful, 151 
"Milk line," 532, Fig. 200, 538 , 
Miscarriage, definition of, 436 

diagnosis of, 440 
Miscarriages and abortions, in clinical 

history, 11 
Mittelschmerz, 132 



642 



INDEX 



Mole, hydatidiform, in Fallopian tube, 
345 

tubal, 344 
Molimina, menstrual, 128 
Mons veneris, Fig. 156, 389 

anatomy of, 388 
Morgagni, columns of, 123, Fig. 191, 
495 

crypts of, 123, Fig. 191, 495 

hydatid of, 327 

valves of, 123, Fig. 191, 495 
"Morris' points," 337 
Morse, J. L., cases of precocious men- 
struation and precocious maturity, 
564 

on bacteriuria, 579 

on hematuria in scurvy, 583 
Mucous patches. See Vulva and Anus 
Muller's ducts, 197, Fig. 71, 198 
Multiple sclerosis, retention of urine in, 

485 
Muscular rheumatism, 19 

of pectoralis major, 553 
Myoma. See Uterus, fibroids of 
Myoma and cancer to be excluded 

from statistics on menopause, 590 

Nabothian Follicles, cysts of, 41, 185 
Nationality, in clinical history, 9 
Nausea and vomiting, symptoms of 

pregnancy, 419 
Neisser, gonococcus of, 179 
Nephritis, acute, anuria in, 156 
Neugebauer, on hermaphroditism, 399 
Neugebauer bivalve speculum, 86 
Neumann, F., cases of joint disease at 

menopause, 616 
Neuralgia, intercostal, in menopause, 
613 

mammary, 539, 553 
Neurasthenia and dysmenorrhea, 130 
Neurasthenia associated with coccy- 

godynia, 159 
New-born, the, genital hemorrhages in, 

571 
Nipple, anatomy of, 532 

discharge from, in late cancer, 553 

discharge of blood from, 545, 546 

Paget's disease of, 548 

retraction of, 553 



Nitze cystoscope, Fig. 56, 116 
Noble, C. P., case of recto- vesical fistula, 
480 
views on fibroids, 246, 253, 255, 256 
Nuck, canal of, hydrocele of, 213 

differentiated from cyst or ab- 
scess of labium, 412 
from hernia, 413 
Nymphse, adherent, 394 
anatomy of, 390 
hypertrophy of, 394 

Obesity, amenorrhea a symptom in, 
141, 419 
associated with premature meno- 
pause, 599 
at menopause, 616 
rapidly occurring, a cause of sterility, 
151 
Occupation, in clinical history, 9 
Odor as a diagnostic sign, 60 
Old age, 622 

conventional time for the beginning 
of, 588 
Olshausen, views on sterility in fibroid 

tumors, 258 
Omentum, cyst of, differentiated from 

ovarian tumor, 3.13 
Oophoron, atrophied because of pres- 
sure, 290 
diagram of, Fig. 120, 290 
Os, parous, Fig. 66a, 169 

virginal, Fig. 66, 168 
Os tincse, 41 

Ostheimer and Levi on enuresis, 579 
Ostium abdominale of tube, Fig. 116, 

285 
Ovaritis, 288 

acute, diagnosis of, 288 
chronic, 290 

diagnosis of, 290 
differentiation of, from small ovarian 
tumor, 297 
Ovary, adhesions about, a cause of 
sterility, 150 
anatomy and age changes of, 284, 592 
and tube seen from behind, Fig. 116, 

285 
anomalies of, 285 
atrophic changes of, in old age, 623 



INDEX 



643 



Ovary, atrophy of, 285 

a cause of amenorrhea, 141 

of sterility, 150 
following steaming of uterine cav- 
ity, 286 
in exanthemata, 285, 599 
lactation, 285 
cancer of, primary, 322 
changes in, at menopause, 592 
corpus luteum of, cysts of, 321, for- 
mation of, 592 
function of, 13 
cyst and tumor of, regions of, Fig. 

120, 290 
cyst of. See Ovary, tumors of, va- 
rieties of: cysts 
large, differentiated from ascites, 
308 
from large fibroid, 309 
showing emaciation and " facies 
ovarina," Fig. 125, 294 
degeneration of, parenchymatous, 
599 
small cystic, 290 
development of, Fig. 71, 198, 592 
diseases of, 284 

in the child, 576 
displacements of, 286 
fibroma of, differentiated from pe- 
dunculated fibroid, 263 
function of, 592 

impaired by infectious diseases, 
577 
Graafian follicles of, degeneration of, 

after infectious diseases, 577 
hernia of, 288 
infantile, Fig. 117, 286 
inflammation of, 288 
normal, palpation of, 41 

position of, 48 
of mature woman, Fig. 118, 287 
prolapse of, 286 

sclerosis of, in tuberculosis, 599 
senile, Fig. 119, 289 
small cystic degeneration of, 290 
tumors of, 291 

a cause of sterility, 150 
aspiration of, 305 
association of, with pregnancy, 
320 



Ovary, tumors of, classification of, 293 
complications of, 315 
cross section of body in, Fig. 127, 

302 
degenerative processes in, 319 
diagnosis of, in general, 295 

in the child, 577 
differential diagnosis of pathologi- 
cal varieties of, 321 
etiology and symptoms of, 293 
Hegar's method of determining- 
relation of, to uterus, Fig. 126, 
301 
in old age, 623 
infantile, Fig. 206, 262 
infection of, 318 
intraligamentous development of, 

316 
large, diagnosis of, 301 

differential diagnosis of, 305 
differentiated from cyst of pan- 
creas, 311 
from cysts of omentum, 313 
from dilated stomach, 314 
from distended bladder, 314 
from echinococcus cysts, 314 
from fat in abdominal walls, 

310 
from fecal accumulation, 309 
from fibroids, 309 
from pregnancy, 305 
from tumors of spleen, liver, 
and kidneys, 312 
inspection of, 302 
palpation of, 302 
percussion of, 303 
malignancy of, 293 
modes of development of, 292 
pedicle formation of, Figs. 121— 

124, 292 
pedicle of, pain caused by traction 
on, 296 
palpation of, 295 
torsion of, 317 
rupture of, 319 
small, diagnosis of, 297 

differential diagnosis of, 297 
differentiated from distended 
bladder, 300 
from echinococcus cyst, 299 



644 



INDEX 



Ovary, tumors of, small, differentiated 
from encapsulated peritoni- 
tis, 298 
from extra-uterine pregnancy, 

299 
from ovaritis, 297 
from parovarian cyst, 298 
from pregnancy, 300 
from subperitoneal fibroid, 

297 
from tumors of the tube, 298 
suppuration of, 318 
symptoms of, 294 
tapping of, 305 
varieties of: 

adhesions and incarceration, 315 
carcinoma, primary, 322 
cysts, dermoid, 322 

differentiation of, from fibroid, 

262 
follicular, 321 
multilocular, 321 
proliferating, 321 
simple, 321 
endothelioma, 323 
fibroma, 322 

differentiation of, from fibroid 
of uterus, 263 
perithelioma, 323 
sarcoma, 322 
teratomata, 322 
undescended, 286 
Ovulation, prolonged, 603 
Ovum, growth of, in early pregnancy, 

423 
Oxyuris vermicularis, a cause of pruri- 
tus, 161 

Paget's disease of the nipple, 548 
Pain following defecation, a symptom 
of fissure or fistula, 157 
in anus, after going to bed, a symp- 
tom of piles or eczema, 157 
in case records, 7 
in clinical history, 18 
in course of ureter, a symptom of 

stricture, 489 
in fibroid tumors, 261 
in groins, in clinical history, 19 
intermenstrual, 132 



Pain, menstrual. See Dysmenorrhea 
Palpation, bimanual, diagram of, Fig. 
5, 38 
for Hegar's sign, Fig. 179, 425 
structures to be felt by, 49 

in diagnosis, 34 

pelvic structures felt by, 40 
Palpitation in fibroids, 259 

in menopause, 613 
Pancreas, cyst of, differentiated from 

large ovarian tumor, 311 
Paralysis, a cause of cystitis, 467 
Paravaginitis, 362 

phlegmonosa dissecans, 362 
Parkinson, J. P., on hematuria, a sign 

of infantile scurvy, 583 
Paroophoron, diagram of, Fig. 120, 

290 
Parovarium, cyst of, 211 
contents of, 211 
differentiated from small ovarian 

tumor, 298 
large cyst seen in profile, Fig. 128, 
303 

diagram of, Fig. 116, 285, 290 
Pathology of disease in any organ. 

See organ affected 
Patient, preparation of, for examina- 
tion, 23 
Pectoralis major muscle, rheumatism 

of, 553 
Pedicle, See Ovary, tumor of, pedicle 

torsion of, 317 
Pediculus pubis, a cause of pruritus, 

161 
Pelvic abscess, 193 

Pelvic cellulitis, 192. See also Cel- 
lulitis, pelvic 

definition of, 187 
Pelvic congestion, a cause of leucorrhea, 

145 
Pelvic inflammation, 187. See also 

Inflammation, pelvic 
Pelvic organs of an infant at birth, seen 

from above, Fig. 206, 562 
Pelvic peritonitis, 188. See also Peri- 
tonitis, pelvic 

definition of, 187 
Pelvimeter, Collyer's, Fig. 42, 98 
Pelvimetry, 95 



INDEX 



645 



Pelvis, abdomen and contents of, 
mechanics of, 44 
cancer of, differentiated from fibroid, 

263 
cavity of, estimating of, 98 
circulation of, 46 
contents of, anatomy of, 43 

from above, Fig. 9, 48 
deformities of, 95, 96 
diameter of, conjugate, Baude- 
locque's, 96 
external conjugate, 96 
oblique conjugate, 97 
oblique diagonal, 98 
transverse, 98 
dimensions of, 95 
female normal, Fig. 9a, 50 

showing accessibility of contents 

to palpation, Fig. 10, 52 
with hand in position for vaginal 
examination, Fig. 4, 37 
floor of, diagram showing structures 
of, Fig. 150, 373. 
injuries of. See Perineum, inju- 
ries of 
lacerations of, 372 
mechanics of, 221 
of new-born child, longitudinal me- 
dian section of, Fig. 204, 558 
outlet of, transverse diameter of, 98 
Penrose, C. B., on erosion of cervix in 

infants, 563 
Percussion of abdomen, 71 
Perineum ("Perineal body"), 221 
development of, Figs. 160-161-162, 

395 
injuries of, a cause of garrulity of 
vagina, 378 
due to coitus, 376 
laceration of, 372 

a cause of sterility, 150 
complete, 374 

median, Fig. 151, 374 
partial, 374 

lateral, Fig. 152, 375 
through the sphincter ani, 37 1 
Peristalsis, waves of, seen on inspection 

of abdomen, 66 
Peritoneum, anatomy of, 188 

folds of, reflections of, Fig. 70, 189 



Peritonitis, body pose in, 67 

encapsulated, differentiated from 

small ovarian tumor, 298 
pelvic, 188 
acute, 190 
chronic, 191 

differential diagnosis of, 195 
etiology of, 189 

in Douglas' cul-de-sac, differen- 
tiated from cellulitis, 195 
tuberculous, 191 
Pessaries, a cause of ulceration of 

vagina, 377 
Pfannenstiel, classification of ovarian 

tumors, 291 
Phantom, bladder, Fig. 58, 118 
"Phantom tumor," 311 
Phthisis, menorrhagia in, 135 
Physician, preparation of, for examina- 
tion, 31 
Piles. See Hemorrhoids 
Pincus, L., views as to atresia of vagina 

following infectious diseases, 560 
"Pinhole os," 41, 81 
Pin-worms, a cause of pruritus, 161 
Placing patient on table, 33 
Poisonings, anuria in, 156 

chronic, amenorrhea a symptom in, 

419 
menorrhagia in, 135 
Polypus and polypi. See Endometritis, 
Uterus, fibroids of, Urethra, and 
Rectum 
Position, dorsal, 33 

for examination, Fig. 3, 32 
knee-chest, Fig. 13, 56 

modified for cystoscopy, Fig. 53, 

111 
side view, Fig. 14, 57 
lithotomy, Fig. 15, 58 
raised pelvis, Fig. 16, 59 
Sims, Fig. 11,53 

diagram of, Fig. 12, 54 
standing, Fig. 17, 60 
Pott's disease, retention and incon- 
tinence of urine in, 485 
Pozzi, S., on development of hymen, 

396 
Precocious maturity, a case of. Fig. 
207, 505 



646 



INDEX 



Pregnancy, a cause of amenorrhea, 141 
a cause of pelvic congestion, 467 
abdominal, 340 

secondary, 345 
abnormal, diagnosis of, 432 
advanced, a cause of retention of 

urine, 155 
associated with ovarian tumor, 320 
breasts in, 420, 421 
diagnosis of, 417 

diagnosis that it has occurred pre- 
viously, 433 
differential diagnosis of, 431 
differentiated from fibroid tumor, 
264 
from large ovarian tumor, 305 
from small ovarian tumor, 300 
during first three months, diagnosis 

of, 418 
during last six months, diagnosis of, 

426 
early, bimanual touch in, 423 
extra-uterine, 340 

differentiated from abortion, 441 
from normal pregnancy, 431 
from small ovarian tumor, 299 
early, 348 

ampullar, Fig. 140, 341 

mole and fetus removed from 
tube in, Fig. 141, 342 
diagnosis after rupture, 351 
late, 350 

ampullar, unruptured, Fig. 145, 

350 
diagnosis of, 353 
section of uterus, showing endome- 
trial modification, Fig. 146, 352 
symptoms and signs of, 346 
in bicornute uterus, 433 
interstitial, Fig. 144, 346 

diagnosis of, 433 
menstruation during, 419 
multiple, diagnosis of, 434 
nausea and vomiting, symptoms of, 

419 
normal, differentiated from small 

ovarian tumor, 300 
ovarian, 345 

pernicious vomiting of, 434 
salivation in, 420 



Pregnancy, symptoms and signs of, 
table of, 430 

tubal, 341 

diseases of ovum in, 345 
fate of fetus in, 344 
mole formed in, 344 

multiple, 348 

pathology of, 343 

repeated, 348 

rupture of, 344 

uterine decidua formed in, 344 

tubo-abdominal, 340 

tubo-ovarian, 340 

tubo-uterine, 340 
Premature labor, definition of, 436 

menopause, 598 
Prepuce, Fig. 156, 389 

a cause of enuresis, 558 

adherent, 394 

in the child, 557 
Present illness, in case records, 7 

in clinical history, 13, 22 

in interpretation of clinical history, 
22 
Previous history, 7, 12 
Probe, uterine, Fig. 22, 82 
Procidentia, Fig. 87, 223 
Procreation, factors essential for, 149 
Proctitis, 505 

acute catarrhal, 506 

atrophic, 507 

chronic catarrhal, 507 

differentiation of atrophic from 
hypertrophic, 509 

dysenteric, 513 

gonorrheal, 510 

hypertrophic, 508 

in children, 585 

simple, 506 

specific, 510 
Proctodeum, development of, Fig. 160, 

395 
Proctoscope, long, Fig. 61, 124 

short, Fig. 60, 123 
Proctoscopy, 124 

Prolapse. See Uterus, prolapse of 
Pruritus vulvae, 160, 404 
Pseudohermaphroditism, 400 
Pseudomasturbation, 574 
Puberty, description of, 14 



INDEX 



647 



Puberty, metrorrhagia of, 573 
Puerperium, a favorable time for be- 
ginning of retroversion, 235 
Purpura, menorrhagia in, 135 

in the child, 572 
Pyosalpinx, 332, Fig. 137, 333 

differentiated from pelvic cellulitis, 
196 
from small ovarian tumor, 298 
rupture of, 333 

Rachford, B. K., on pseudomastur- 

bation, 574 
Raised pelvis position, 58 
Reconstruction of uterus, Fig. 64, 166 
Rectal speculum, Sims, Fig. 63, 126 
Rectal symptoms, 156 
Recti muscles, separation of, 66 
Rectocele, 369, Fig. 149, 369 
at menopause, 621 
diagram of, Fig. 149a, 370 
Rectum, adenoma of, 523 
anatomy of, 121 
anomalies of, 495 
cancer of, 525 
diagnosis of, 528 
differential diagnosis of, 528 
frequency of, 525 
hemorrhage as a symptom of, 157 
pathology and course of, 526 
symptoms of, 527 
chancre of, 512 
chancroids of, 512 

development of, Figs. 158-162, 395 
digital examination of, 123 
discharge from, as a symptom, 157 
diseases of, 494 

in children, 584 
exudate about a fistula of, differen- 
tiated from cancer, 528 
fecal accumulation in, as a symptom, 

157 
fibro-adenoma of, 523 
fibroma of, 524 
gumma of, 512 

differentiated from cancer, 529 
hemorrhage from, as a symptom, 157 
imperforate, 496, 561 
inflammation of, 505. See also 
Proctitis 



Rectum, inspection of, 124 
lower part of, Fig. 195, 515 
lymphadenoma of, 523 
new growths of, 522 
pain in, as a symptom, 156 
polyp of, differentiated from cancer, 
529 

fibrous, 524 

glandular, 524 

hemorrhage as a symptom of, 157 

mucous, 523 

myomatous, 524 

myxomatous, 525 
prolapse of, 521 

complete, 522 

hemorrhage as a symptom of, 157 

in children, 584 

incomplete, 522 
sarcoma of, 529 
stricture of, 518 

congenital, 519 

differentiated from cancer, 529 

due to pressure from without, 519 

inflammatory, 519 

spasmodic, 519 
syphilis of , 510 
syphilitic ulceration of, 512 
tuberculosis of, 513 
tuberculous ulceration of, differen- 
tiated from cancer, 528 
veins of, 123 
villous tumor of, 524 

differentiated from cancer, 529 
Rectus muscle, fibromyoma of, 310 
Reflections of folds of peritoneum, Fig. 

70, 189 
Rheumatic diathesis and pruritus 

vulvae, 161 
Rheumatism, at menopause, 616 
muscular, 19 

of pectoralis major, 553 
Richardson, M. H., on evils of too posi- 
tive an opinion about breast 

tumors, 549 
on importance of making a complete 

physical examination in the case 

of breast tumors, 554 
Riviere, A., case of incontinence of 

feces in a girl of nine, 586 
Robb leg-holders, 57 



648 



INDEX 



Rodman, W. L., analysis of 5,000 cases 
of cancer of the breast, 551 
on operability of cancer of the breast, 

549 
on the three most important points 
in diagnosis of tumors of the 
breast, 550 
Rossi-Doria, delayed menstruation and 

pelvic disease, 15 
Round ligaments. See Ligaments, 

round 
Rupture of ovarian cyst by forcible 
manipulations, 319 

Sacro-iliac subluxation, 18 
Sactosalpinx, 332 

diagnosis of, 335 
Salpingitis, 327 

actinomycotic, 332 

acute, 327 

catarrhal, 327 

chronic, 329 

diagnosis of, 328 

differentiated from appendicitis, 336 

echinococcic, 332 

follicular, a cause of sterility, 151 

gonorrheal, 330 

obliterating, a cause of sterility, 150 

purulent, 328 

symptoms of, 328 

syphilitic, 332 

tuberculous, 330, Fig. 136, 331 
Sampson, J. A., on pain caused by 

twisting pedicle of tumor, 296 
Sanger, M., on chorioepithelioma, 280 
Sapremia, 175 
Schulkowski, on genital hemorrhage in 

the new-born, 572 
Sclerosis, multiple, retention of urine 

in, 485 
Scurvy, hematuria in, 583 

menorrhagia in, 135 
Sea voyages, amenorrhea following, 419 
Searcher, ureteral, Kelly, Fig. 47, 102 
Searching urethra and bladder, 108 
Separator, urine, Luys, Fig. 59, 119 
Sepsis. See Endometritis, acute septic 
Septicemia, 175 

Sexual feeling at menopause, 614 
Simon speculum, 86 



" Simpson symptom " of cancer of body 

of uterus, 276 
Sims position, 54 

rectal speculum, Fig. 63, 126 
vaginal speculum, 88 
Sinus, urogenital, persistence of, 393, 
444 
urogenitalis, Fig. 71, 198, Fig. 157, 
392, Fig. 160, 395 
Skene's glands, anatomy of, 101 
collection of discharges from, 61 
lurking-places for infection, 180 
Slanting shelf formed by psoas muscles 

and false pelvis, Fig. 86, 221 
Social condition, in clinical history, 10 
Souffle, uterine, 429 
Sound, uterine, 78, Fig. 21, 78 
caution in use of, 82 
facts to be learned by use of, 80 
how to pass bimanually, 79 

by sight, 80 
when to pass, 78 
Sound touch, 81 
Spasm of bladder, 109, 465 
Speculum, rectal, Sims, Fig. 63, 126 
uterine, Burrage, Fig. 36, 93 
vaginal, 85 
bivalve, 85 

Brewer, Fig. 26, 87 
Edebohls, 86, Fig. 32, 91 
Graves bivalve, Fig. 27, 87 
Sims, 87, Fig. 28, 88. 
Speese, John, on predisposition to 
cancer furnished by lactation mas- 
titis, 544 
Sphincter ani, action of, preventing 
healing of fissure, 123 
external, Fig. 195, 515 
hypertrophy of, in hemorrhoids, 503 
internal, Fig. 195, 515 
method of stretching of, 126 
Spinal cord, disease of, a cause of in- 
continence of urine, 155 
Spirochoeta pallida, in chancre of vulva, 
407 
in mucous patches of vulva, 407 
Spleen, tumors of, differentiated from 
ovarian tumors, 312 
wandering, differentiated from ova- 
rian tumor, 312 



INDEX 



649 



Stammering of bladder, 109, 465 
Starfinger on sarcoma of vagina in 

children, 382 
Stark, M. M., cases of premature meno- 
pause, 600 
Stephenson. W., on menstrual wave 

theory, 595 
Sterility, 147 

age as affecting, 148 

conditions of uterine organs that 
interrupt pregnancy, 150 

constitutional diseases causing, 151 

due to anomalies and diseases of 
uterine organs, 150 

in the male, 148 
Stomach, dilated, differentiated from 

ovarian tumor, 314 
Stone in bladder, 462 

in children, 582 
Storer, M., cases of bilateral torsion of 

Fallopian tubes, 336 
Straining, a cause of hemorrhoids, 500 

at stool, with sense of only partial 
relief, a symptom of stricture of 
rectum, 158 
Strangury, 152 
Stricture of rectum. See Rectum, 

stricture of 
Subinvolution, 207 
Sunstroke, anuria in, 156 
Swelling of feet and legs in fistula in 

ano, 520 
Symptoms of disease in any organ. 

See organ affected 
Syphilis. See organ affected 

a cause of abortion, 437 

a cause of sterility, 151 

menorrhagia in, 135 

Table, examining, preparation of, 26 
Tachycardia, in fibroids, 259 

in menopause, 613 
Taylor, case of late conception, 603 
Tenaculum, uterine. Fig. 24, 83 
Tenaculum forceps, double 85 
Thornton, case of ovariotomy on 

woman ninety-four years old, 294 
Thyroid. See Gland 
Tilt, E. J., cases of prolonged mensl ru- 
ation, 604 



Tilt, table of comparative dates of 
cessation of menstruation in dif- 
ferent countries, 598 
table of uterine diseases foimd during 

menopause, 589 
views on length of dodging time, 611 
Tissue, preservation of, 63 

removal of, for microscopic exami- 
nation, 62 
Torsion of uterus, 244 
Touch, bimanual, diagram of, Fig. 5, 38 
hindrances to, 39 
structures to be felt by, 49 
vagino-abdominal, 38 
rectal, 50 
recto-abdominal, 53 

in examination of children, 556 
sound, 81 
vaginal, 31 
vagino-abdominal, 38 
Townsend, C. W., on incontinence of 
urine relieved by removal of rectal 
polyp, 579 
Treatment advised, in case records, 8 
Trigone, hyperemia of, 471 
Trigonitis, 471 

Tube, Fallopian, a carrier of infection 
to ovarian tumors, 318 
absence of, 326 
accessory, 326 
anatomy of, 324 
anomalies of, 326 
atrophic changes in, in old age, 623 
atrophy of, at menopause, 594 
carcinoma of, 338 
chorioepithelioma of, 339 
cyst of Morgagni of, 327 
diseases of, 324 

in the child, 576 
displacement of, 326 
diverticula from, 326 
elongation of, 326 
embryoma of, 338 
fibroma of, 338 
fibromyxoma of, 338 
function of, 325 
hernia of, 326 
infantile. Fig. 206, 562 

inflammation of, 327 
myoma of, 338 



650 



INDEX 



Tube, Fallopian, new growths of, 337 
papilloma of, 337 
polypus of, 337 
retention tumors of, 332 

rupture of, 336 
sarcoma of, 339 

tumors of, differentiated from 
small ovarian tumors, 298 
Tuberculosis. See organ affected 

amenorrhea a symptom in, 419 
Tubo-ovarian cyst, 334 
Tumor of any organ. See organ 
affected 
rising from pelvis, outlined by ab- 
dominal walls, 66 
Turpentine, a cause of cystitis, 467 
Tuttle, J. P., on frequency of cancer of 

rectum, 525 
Typhoid fever, anuria in, 156 

Underhill, F. P., and Rand, R. F., 

on the urine in pernicious vomiting 

of pregnancy, 436 
Urachus, cyst of, differentiated from 

ovarian tumor, 311 
Uremia, anuria in, 156 

menorrhagia in, 135 
Ureter, absence of, 486 

anatomy of, 103 

anomalies of, 486 

blood clot in, a cause of stricture, 489 

calculus of, 490 

cancer of, a cause of stricture, 489 

catheterization of, 115 

compression of, by fibroid, 257 

development of, Fig. 71, 198 

diseases of, 486 

double, 486 

echinococcus cyst in, a cause of stric- 
ture, 489 

fistulae of, 492 

gumma of, a cause of stricture, 489 

inflammation of, 488 

mucosa of, prolapse of, 491 

new growths of, 493 

occluded, cystic dilatation of, 487 

orifice of. See Bladder, anatomy of 
abnormal situation of, 486 
swollen, 488 
urine spurting from. Fig. 52, 107 



Ureter, stone in, 490 

a cause of stricture, 489 

stricture of, 489 

tumors of, 493 

valve formation in, 489 
Ureteritis, 488 
Urethra, anatomy of, 100 

angioma of, 453 

anomalies of, 444 

atresia of, 445 

bladder and, searching of, 106 

bladder and ureters, and, examina- 
tion of, 107 

cancer of, 455 

caruncle of, 453, Fig. 184, 454 
a cause of dysuria, 152 
of sterility, 150 
of vaginismus, 379 
differentiated from cancer, 415, 
455 
from prolapse of muscosa, 449 

development of, Fig. 71, 198, 
Figs. 160-162, 395 

dilated and short, 444 

dilatation of, 447 
limits to, 448 

diseases of, 444 

dislocation of, downward, 109, 446 
upward, 445 

external, partial defect of, 444 

fibroma of, 455 

granuloma of, 453 

inflammation of, 450 

mucosa of, prolapse of, 448 

mucous membrane of, prolapse of, 
Fig. 183, 449 

mucous polyp of, 453, 455 

myoma of, 455 

new growths of, 453 

polyp of, differentiated from pro- 
lapse of mucosa, 449 

sarcoma of, 456 

stricture of, 452 

a cause of frequency of micturi- 
tion, 154 

tuberculosis of, differentiated from 
cancer, 455 
Urethritis, 450 

a cause of dysuria, 152 

of frequency of micturition, 154 



INDEX 



651 



Urethritis, acute, 450 

chronic, circumscribed, 451 
diffuse, 451 
Urethrocele, differentiated from dislo- 
cation of urethra, 447 
Urination, difficult, retarded or pain- 
ful, 151 
too frequent, 153 
Urine, analysis of, in case records, 8 
incontinence of, 154, 485 

a symptom of abnormal opening 
of ureter, 487 
method of collecting, in children, 578 
retention of, 155 

in incarceration of retroflexed 
pregnant uterus, 155 
suppression of, 156 
Urogenital sinus, Fig. 71, 198, Fig. 157, 
392, Fig. 160, 395 
persistence of, 393 
Uterine disease, a cause of hemorrhoids, 
500 
influence of, on menopause, 617 
symptoms of, 127 
Uterine ligaments. See Ligaments, 

uterine 
Uterine organs, atrophic changes in, 

at menopause, 594 
Uterine segment, lower, true hypertro- 
phic elongation of, 229 
Uterus, abnormalities of axis and form 
of, 234 
absence of, 198 
adenomyoma of, 245 
symptoms of, 262 
anomalies of, 197 

due to arrest of development, 201 
due to arrest of growth, 202 
anteflexion of, 240. See also Retro- 
position with anteflexion 
a cause of sterility, 150 
in the little girl, Fig. 90, 230 
pathological, Fig. 91, 231 
anteroposition of, 229 
anteversion of, 238 
ascent of, 218 

atrophic changes in, in old age, 624 
atrophy of, at menopause, 594 
congenital, 140, 203 
following steaming, 286 



Uterus, atrophy of, lactation, 203 
non-puerperal, 203 
puerperal, 203 
bicornis, 200 

diagram of, Fig. 74, 199 
bicornute, Fig. 78, 201 

pregnancy in, 433 
bipartitus, Fig. 72, 199, 200 
body of, cancer of, adeno-carcinoma, 
269 
early stage of, Fig. 112, 269 
diagnosis of, 276 
differential diagnosis of, 277 
differentiated from fibroid, 265 
sarcoma of, 279, Fig. 113, 279 
cancer of, 266 

a cause of hemorrhage at meno- 
pause, 619 
diagnosis of, in general, 270 
in the child, 576 
leucorrhea in, 271 
symptoms of, 270 
cavity of, digital exploration of, 94 
Kelly's method of exploration of, 
94 
Figures illustrating, Figs. 38-41, 
94-97 
cervix of. See Cervix 
chorioepithelioma of, diagnosis of, 283 
differentiated from fibroid, 265 
malignant, 280 
of posterior wall, Fig. 114, 281 
decidua in, in extra-uterine preg- 
nancy, Fig. 143, 345 
didelphys, Fig. 73, 199, 200 
double, with double vagina, Fig. 147, 

358 
fibro-cystic tumor of, 253 
fibroid in anterior wall of, differen- 
tiated from pregnancy, 431 
fibroids of, 244 

a cause of delayed menopause, 604 
of hemorrhage at menopause, 
617 
anemia in, 261 
carcinoma complicating, 255 
cervical, 247 
classification of, 245 
complications of, 255 
course and development of, 251 



52 



INDEX 



Uterus, fibroids of, dangerous to life, 

260 
degenerations in, 252 

amyloid, 254 

colloid, 253 

fatty, 253 

hyaline, 253 

myxomatous, 253 

sarcomatous, 255 

in differential diagnosis, 264 
diagnosis and differential diagnosis 

of, 262 
differentiated from large ovarian 
cyst, 309 

from small ovarian tumors, 298 
diseases of tubes and ovaries com- 
plicating, 256 
edema in, 254 

effect of, on distant organs and 
system, 258 

on neighboring organs, 257 
etiology of, 250 
fibro-cystic, 253 
frequency of, 248 
gangrene in, 254 
globular, filling pelvis, Fig. 109, 

256 
heart disease in relation to, 259 
hemorrhage in, 260 
in negro race, 249 
interstitial, 247 

diagnosis of, 263 
interstitial and submucous, Fig. 

104, 248 
intraligamentous, 246, Fig. 105, 
249 

diagnosis of, 263 
dysmenorrhea in, 129 
leucorrhea in, 261 
metastases in, 255 
multiple, Fig. 102, 246 

of cervix, 247, Fig. 108, 254 
pain in, 261 
palpitation in, 259 
pathology of, 244 
pedunculated or polypus, differen- 
tiated from prolapse, 229 

in vagina. Fig. 107. 252 
pregnancy interfered with by, 258 
renal complications in, 257 



Uterus, fibroids of, rupture of uterus 
in, 260 
sarcoma in, 264 
seedling, 251 
situation of, 248 
sloughing, 248 
submucous, 247 
diagnosis of, 264 
intra-uterine, differentiated from 

incomplete inversion, 243 
large, Fig. 106, 250 
pedunculated, in vagina, differ- 
entiated from complete in- 
version, 242 
subperitoneal, a cause of stricture 
of ureter, 489 
differentiated from small ova- 
rian tumor, 297 
subserous, 246 
diagnosis of, 262 
differentiated from pelvic cellu- 
litis, 196 
side view of abdomen contain- 
ing large, Fig. 103, 247 
suppuration in, 254 
symptoms of, 260 
thrombosis in, 255 
ureters compressed by, 257 
fundus of, height of, at various weeks 

of pregnancy, Fig. 130, 306 
gravid, changes in, during early 

pregnancy, 423 
hernia of, 233 
horizontal section of body showing 

shape of cavity of, Fig. 67, 171 
hyperinvolution of, a cause of steril- 
ity, 150 
infantile, 140, 202, Fig. 204, 558 
a cause of amenorrhea, 140 
of sterility, 150 
inversion of, 240 

acute puerperal, Fig. 93, 239 

and conditions simulating, Figs. 

94-101, 241 
diagnosis of, 240 

differential diagnosis of (table), 242 
differentiated from fibroid, 242, 
243, 265 
from prolapse, 228 
lateroposition of, 229 



INDEX 



653 



Uterus, ligaments of. See Ligaments 
lower segment of, softening of, in 

pregnancy, 425 
maldevelopment of, a cause of dys- 
menorrhea, 129 

amenorrhea a symptom of, 419 
malpositions of, 215 

at menopause, 620 

mechanism of, 219 
muscular wall of, sarcoma of, 280 
non-puerperal atrophy of, 203 
normal, mobility of, 49 
normal position of, 43, Fig. 6, 44, 

Fig. 84, 216, Fig. 150, 373 
polyp of, simulating prolapse, 229 
polyp of, a cause of hemorrhage at 
menopause, 618 

mucous, simulating cancer, 273 
pregnant, at sixth week, diagramma- 
tic side view, during contraction, 
Fig. 178, 423 

during relaxation, Fig. 177, 
422 

changes in shape of, during early 
pregnancy, 423 

contractions of, 424 

enlargement of, in late pregnancy, 
Fig. 181, 428 

palpation of, in late pregnancy, 428 

retroflexion and incarceration of, 
432 

shape of, in early pregnancy, 423 

situation of, in early pregnancy, 423 

six weeks', section of, Fig. 178, 424 
prolapse of, 218, Fig. 87, 223 

a cause of sterility, 150 

acute, 218 

at menopause, 620 

causation of, 223 

diagnosis of, 226 

differential diagnosis of, 228 

in the child, 562 

mechanism of. 219 

partial, Fig. 89, 227 

pathology of, 218 

symptoms and course of, 226 
reconstruction of, showing shape of 

cavity, Fig. 64, 166 
retroflexion of, differentiated from 

pregnancy, 431 



Uterus, retroposition of, 230 

with anteflexion, 231, Fig. 91, 231 
diagnosis of, 232 
differentiated from pregnancy, 

231 
dysmenorrhea in, 129 
retroversio-flexion of, 234 
diagnosis of, 236 
etiology of, 235 
mechanism of, 222, 235 
retroversion of, 234, Fig. 92, 235 
a cause of menorrhagia, 137 

of sterility, 151 
caused by an overdistended blad- 
der, Fig. 84, 218 
rudimentary, 198 
sarcoma of, 278, Fig. 113, 279 

in the child, 576 
septus, 200, Fig. 75, 198 
souffle of, 429 
subinvolution of, 207 

a cause of hemorrhage at meno- 
pause, 618 
differentiated from pregnancy, 431 
supravaginal elongation of, Fig. 88, 

226 
torsion of, 243 
transverse longitudinal section of, 

Fig. 68, 172 
tubes, vagina, and, development of, 

Fig. 71,198 
unicornis, Fig. 76, 199, 200 

with accessory cornu, Fig. 77, 199 
walls of, structure of, 167 

Vagina, absence of, 356 

age changes in, 356 

anatomy of, 354 

anterior fornix of, 354 

anterior wall, tumor of, differen- 
tiated from cystocele, 368 

appearance of, in early pregnancy, 
421 

atresia of, a cause of amenorrhea, 142 
of dysmenorrhea, 129 
of sterility, 150 
acquired, 359 
congenital, 357 

;ii rophic changes in, in old age, 625 

atrophy of, at menopause, 595 



654 



INDEX 



Vagina, cancer of, 383 
chorioepithelioma of, metastatic, Fig. 
115, 282 

primary, 384 

secondary, Fig. 115, 282 
column of, 355 
condylomata of, 384 
cross section of, Fig. 151, 374 
cysts of, 379 

in anterior wall, Fig. 154, 381 

in posterior wall, Fig. 153, 380 
development of, Figs. 158-161-162, 

395 
discharge from, normal, 143, 355. 

See also Leucorrhea 
diseases of, 354 
displacements of, 366 
double, 357, Fig. 147, 358 
enterocele of, 371 
examination of, in children, 556 
fibroids of, 381 
fistulse of, 384 

scheme of, Fig. 155, 385 
foreign bodies in, 377 
garrulity of, 378 
gas in, 378 
hematoma of, 377 
hernia of, 368, 371 

differentiated from cystocele, 368 
inclusion cyst of posterior wall of, 

Fig. 153, 380 
infantile, examination of, with cysto- 

scope, Fig. 205, 559 
inflammations of, 361 
injuries of, 371 

at menopause, 621 

due to coitus, 376 

due to falls on sharp bodies, 
377 

due to unskillful instrumentation, 
377 

etiology of, 371 
longitudinal section of, showing 

S-shaped curve, Fig. 85, 219 
malformations of, 356 
myoma of, 381 
new growths of, 379 
palpation of, 34 
posterior fornix of, 355 
prolapse of, Fig. 88, 224 



Vagina, sarcoma of, 381 
in adults, 382 
in children, 382, 570 

septate, 357 

stenosis of, acquired, 359 
Vaginal touch. See Touch, vaginal 
Vaginismus, 378 

a cause of dyspareunia, 146 
of sterility, 150 
Vaginitis, 361 

a cause of sterility, 150 

acute, 362 

chronic, 363 

condylomatous, 363 

diphtheritic, 362 

emphysematosa, as a cause of gar- 
rulity of vagina, 378 

emphysematous, 364 

erysipelatous, 362 

exfoliative, differentiated from mem- 
branous dysmenorrhea, 131 

gonorrheal, 363 

mycotic, 364 

pseudo-diphtheritic, 362 

senile, 365 

syphilitic, 365 

tuberculous, 365 

ulcerative, 364 

with bacillary dysentery, 364 
Valves, Houston's, 122 

semilunar, of rectum, 122, 123 
Vander Veer, operations on pregnant 

women by mistake, 417 
Varicocele and varix. See Ligament, 

broad, and Vulva 
Veit, J., on chorioepithelioma, 282 

on garrulity of the vagina due to a 
gas-forming bacillus, 378 

on vaginal atresia, a cause of hema- 
tocolpos, 359 
Vesical symptoms, 151 

at menopause, 621 
Vestibule, Fig. 156, 389 

anatomy of, 390 
Vinay, L., on goitre and the menopause, 
593 

on sclerosis of the ovaries in tubercu- 
losis, 599 
Vineberg, views on lactation atrophy of 

uterus, 203 



INDEX 



655 



Volkmann, on acute carcinoma of 

mastitis, 543 
Vomiting of pregnancy, 434 
Von Ott leg holders, 57 
Vulva, age changes in, 391 
anatomy of, 388 
angioma of, 413 
anomalies of, 391 
at beginning of third month of fetal 

life, Fig. 157, 392 
atrophic changes in, in old age, 625 
benign tumors of, 413 
cancer of, 414 
chancre of, 406 

differentiated from cancer, 415 
chancroids of, 406 

differentiated from cancer, 415 
condylomata of, differentiated from 

cancer, 415 
condylomata acuminata of, 407 
condylomata lata of, 407 
congestion of, a cause of pruritus, 

161 
development of, 392 
diagram of, Fig. 156, 389 
diseases of, 388 

eczema of, a cause of pruritus, 161 
edema of, 405 
elephantiasis of, 404 
fibroma of, 413 
furunculosis of, differentiated from 

chancre, 407 
gangrene of, 405 

in the child, 569 
gumma of, 408 
hematoma of, 400 
herpes of, differentiated from chancre, 

407 
in early pregnancy, appearance of, 

421 
infantile, Fig. 203, 556 
inflammation of, 402 
injuries of, 400 

due to coitus, 401 

due to direct violence, 401 
inspection of, 33 
itching of, 160,404 
lipoma of, 413 

in a child, 573 
malignant tumors of, 414 



Vulva, mucous patches of, 407 
myoma of, 413 
myxoma of, 413 
neuroma of, 413 
noma of, 405 

in the child, 569 
sarcoma of, 416 
thrush of, 403 

a cause of pruritus, 161 
tuberculosis of, 408 

differentiated from cancer, 415 

in the child, 568 
tumors of, a cause of sterility, 150 
uncleanliness of, a cause of pruritus, 

161 
varicose veins of, 405 
varix of, 405 

a cause of pruritus, 161 
venereal lesions of, 406 
Vulvitis, a cause of pruritus, 161 
catarrhal, 402 
diabetic, 403 

diphtheritic, in the child, 569 
gonorrheal, 402 
simple, 402 
Vulvo-vaginitis in children, 566 
diagnosis of, 568 
symptoms of, 568 

Warker, Van de, on frequency of 

strictures of urethra, 452 
Wathen uterine dilator, Fig. 34, 92 
Webster, J. C, case of wandering 
spleen in iliac fossa, 312 
on renal complications in fibroid 
tumors, 257 
Wertheim, views on latent gonorrhea, 

182 
Whites. See Leucorrhea 
Williams, J. W., cases of ovarian preg- 
nancy, 245 
on etiology of extra-uterine pregnan- 
cy, 342 
on pernicious vomiting of pregnancy, 
434 
Winckel, case of spontaneous healing 
of vesico-vaginal fistula following 
subsequent pregnancy, 477 
Winter, cancer propaganda in East 
Prussia, 270 



656 



INDEX 



Winter, observations on the heart in 
fibroid tumors, 259 
on metastases in sarcoma of the 
uterus, 280 
Wischmann, C, case of precocious ma- 
turity, 564 
Worry, polyuria in, 485 



X-rays in diagnosis, 76 

Young Girls, examination of, 25 

Zappert, J., on genital hemorrhages in 
the new-born, 572 

Zweifel, views on frequency of gonor- 
rhea, 179 



JUL 



One copy del. to Cat. Div. 



12 18 )* 



